This form structure is an organized set of data definitions for a form that has not been copyrighted

 General Details

Title:
Post-Concussion Symptom Inventory - Parent (PCSI-P)
Short Name:
PCSI_P
Description:
The Post-Concussion Symptom Inventory - Parent (PCSI-P) focuses on symptoms in the cognitive, emotional, sleep, and physical domains. Recommended by CDISC for TBI (TAUG TBI)
Disease:
Traumatic Brain Injury
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2015-12-23
Version:
1.2
Date Created:
2015-12-23
Owner:
Number of Data Elements:
66
eForms:
N

 Documentation


 Groups & Attached Data Elements

Logically grouped data elements with defined frequency at which they repeat.

# Title Short Description Variable Name Required? Type
1 GUID   Global Unique ID which uniquely identifies a subject GUID Required CDE
2 Subject identifier number   An identification number assigned to the participant/subject within a given protocol or a study. SubjectIDNum Optional CDE
3 Age in years   Value for participant's subject age recorded in years. AgeYrs Recommended CDE
4 Vital status   Status of participant/subject as alive or dead VitStatus Optional CDE
5 Visit date   Actual interview or visit date VisitDate Recommended CDE
6 Site name   The name of the site for the study SiteName Recommended CDE
7 Days since baseline   The number of days since baseline DaysSinceBaseline Optional CDE
8 Case control indicator   Indicator of whether subject is in the case or control arm of the study CaseContrlInd Optional CDE
9 General notes text   General notes GeneralNotesTxt Optional CDE

Additional Element Groups

Listed below are your additional element groups.

Form Administration (Repeat Infinitely)

# Title Short Description Variable Name Required? Type
1 Context type  The context to which the questions were answered ContextType Recommended CDE
2 Context type other text  The free-text related to ContextType specifying other text ContextTypeOTH Recommended CDE
3 Data source  Source of the data provided on the case report form DataSource Recommended CDE
4 Data source other text  The free-text field related to Data source specifying other text. Source of the data provided on the case report form DataSourceOTH Recommended CDE

Before the Injury/ Pre-Injury (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Headache scale  Scale to which the subject complained of headaches, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPHeadacheScale Recommended CDE
2 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Nausea scale  Scale to which the subject complained of nausea, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPNauseaScale Recommended CDE
3 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Vomit scale  Scale to which the subject vomited, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPVomitScale Recommended CDE
4 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Balance problem scale  Scale to which the subject experienced balance problems, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPBalanceProbScale Recommended CDE
5 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Dizziness scale  Scale to which the subject appeared or complained of dizziness, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPDizzinessScale Recommended CDE
6 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Trouble falling asleep scale  Scale to which the subject had trouble falling asleep, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPTroubleFallAsleepScale Recommended CDE
7 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Sleep more than usual scale  Scale to which the subject slept more than usual, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPSleepMoreThanUsualScale Recommended CDE
8 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Sleep less than usual scale  Scale to which the subject slept less than usual, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPSleepLessThanUsualScale Recommended CDE
9 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Drowsy scale  Scale to which the subject appeared drowsy, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPDrowsyScale Recommended CDE
10 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Sensitive to light scale  Scale to which the subject was sensitive to light, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPSensitiveToLightScale Recommended CDE
11 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Sensitive to noise scale  Scale to which the subject was sensitive to noise, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPSensitiveToNoiseScale Recommended CDE
12 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Irritable scale  Scale to which the subject was irritable, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPIrritableScale Recommended CDE
13 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Sad scale  Scale to which the subject appeared sad, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPSadScale Recommended CDE
14 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Nervous scale  Scale to which the subject acted nervous, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPNervousScale Recommended CDE
15 Post-Concussion Symptom Inventory - Parent (PCSI-P) - More emotional scale  Scale to which the subject acted more emotional, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPMoreEmotionalScale Recommended CDE
16 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Numbness or tingling scale  Scale to which the subject had or complained of numbness or tingling, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPNumbnessTinglingScale Recommended CDE
17 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Slowed down scale  Scale to which the subject acted or appeared slowed down, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPSlowedDownScale Recommended CDE
18 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Mentally foggy scale  Scale to which the subject acted or appeared mentally "foggy", as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPMentallyFoggyScale Recommended CDE
19 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Difficult to concentrate scale  Scale to which the subject had difficulty concentrating, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPDiffConcentrateScale Recommended CDE
20 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Difficult to remember scale  Scale to which the subject had difficulty remembering, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPDiffRememberScale Recommended CDE
21 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Visual problems scale  Scale to which the subject had or complained of visual problems (blurry, double vision), as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPVisualProbScale Recommended CDE
22 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Tired or fatigued scale  Scale to which the subject appeared more tired or fatigued, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPTiredFatiguedScale Recommended CDE
23 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Dazed or stunned scale  Scale to which the subject appeared dazed or stunned, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPDazedStunnedScale Recommended CDE
24 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Confused scale  Scale to which the subject became confused with directions or tasks, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPConfusedScale Recommended CDE
25 Post - Concussion Symptom Inventory - Parent (PCSI-P) - Clumsy scale  Scale to which the subject appeared to move in a clumsy manner, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPClumsyScale Recommended CDE
26 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Answer slowly scale  Scale to which the subject answered questions more slowly than usual, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPAnswerSlowlyScale Recommended CDE

Within the Last Few Days (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Headache scale  Scale to which the subject complained of headaches, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPHeadacheScale Recommended CDE
2 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Nausea scale  Scale to which the subject complained of nausea, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPNauseaScale Recommended CDE
3 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Vomit scale  Scale to which the subject vomited, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPVomitScale Recommended CDE
4 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Balance problem scale  Scale to which the subject experienced balance problems, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPBalanceProbScale Recommended CDE
5 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Dizziness scale  Scale to which the subject appeared or complained of dizziness, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPDizzinessScale Recommended CDE
6 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Trouble falling asleep scale  Scale to which the subject had trouble falling asleep, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPTroubleFallAsleepScale Recommended CDE
7 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Sleep more than usual scale  Scale to which the subject slept more than usual, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPSleepMoreThanUsualScale Recommended CDE
8 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Sleep less than usual scale  Scale to which the subject slept less than usual, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPSleepLessThanUsualScale Recommended CDE
9 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Drowsy scale  Scale to which the subject appeared drowsy, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPDrowsyScale Recommended CDE
10 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Sensitive to light scale  Scale to which the subject was sensitive to light, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPSensitiveToLightScale Recommended CDE
11 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Sensitive to noise scale  Scale to which the subject was sensitive to noise, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPSensitiveToNoiseScale Recommended CDE
12 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Irritable scale  Scale to which the subject was irritable, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPIrritableScale Recommended CDE
13 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Sad scale  Scale to which the subject appeared sad, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPSadScale Recommended CDE
14 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Nervous scale  Scale to which the subject acted nervous, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPNervousScale Recommended CDE
15 Post-Concussion Symptom Inventory - Parent (PCSI-P) - More emotional scale  Scale to which the subject acted more emotional, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPMoreEmotionalScale Recommended CDE
16 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Numbness or tingling scale  Scale to which the subject had or complained of numbness or tingling, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPNumbnessTinglingScale Recommended CDE
17 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Slowed down scale  Scale to which the subject acted or appeared slowed down, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPSlowedDownScale Recommended CDE
18 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Mentally foggy scale  Scale to which the subject acted or appeared mentally "foggy", as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPMentallyFoggyScale Recommended CDE
19 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Difficult to concentrate scale  Scale to which the subject had difficulty concentrating, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPDiffConcentrateScale Recommended CDE
20 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Difficult to remember scale  Scale to which the subject had difficulty remembering, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPDiffRememberScale Recommended CDE
21 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Visual problems scale  Scale to which the subject had or complained of visual problems (blurry, double vision), as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPVisualProbScale Recommended CDE
22 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Tired or fatigued scale  Scale to which the subject appeared more tired or fatigued, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPTiredFatiguedScale Recommended CDE
23 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Dazed or stunned scale  Scale to which the subject appeared dazed or stunned, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPDazedStunnedScale Recommended CDE
24 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Confused scale  Scale to which the subject became confused with directions or tasks, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPConfusedScale Recommended CDE
25 Post - Concussion Symptom Inventory - Parent (PCSI-P) - Clumsy scale  Scale to which the subject appeared to move in a clumsy manner, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPClumsyScale Recommended CDE
26 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Answer slowly scale  Scale to which the subject answered questions more slowly than usual, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPAnswerSlowlyScale Recommended CDE

Generally Different (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Post-Concussion Symptom Inventory - Parent (PCSI-P) - Generally different scale  Scale to which the subject generally seemed to be acting differently than before the injury, as part of the Post-Concussion Symptom Inventory - Parent (PCSI-P). PCSIPGenerallyDifferentScale Recommended CDE

 Change History

 Administrative Change History