This form structure is an organized set of data definitions for a copyrighted form

 General Details

Title:
Pediatric Quality of Life Inventory (PedsQL) Family Information Form
Short Name:
PedsQLFamInfForm
Description:
The PedsQL Family Information Form, completed by parents, contains demographic information on the child and parents, including the childÂ’s date of birth, gender, race/ethnicity, and parental education information and whether the child has a chronic health condition. It also asks for information on the number of days during the past 30 days that the child needed care or missed school because of health, the number of days the parent missed work because of the child's health, and the impact of the child's health on the parent's daily work routine and ability to concentrate at work. The PedsQL Family Information Form contains the demographic information required to calculate the Hollingshead socioeconomic status (SES) index (Hollingshead, 1975). Copyright 1998 JW Varni, PhD. All rights reserved. Varni, James W., Michael Seid, and Paul S. Kurtin. Pediatric health-related quality of life measurement technology: A guide for health care decision makers. JCOM-WAYNE PA- 6 (1999): 33-44.
Disease:
General (For all diseases) , Traumatic Brain Injury
Organization:
NIH/CIT/BRICS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-11-07
Owner:
Number of Data Elements:
30
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 (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Language form administration ISO code  Code (ISO 639-2) for the language that was used for CRF/instrument/scale/etc. administration LangCRFAdministratISOCode Recommended CDE
2 Language form administration ISO code other text  The free-text field related to 'Language used for CRF/instrument/scale/etc. administration ISO code' specifying other text. LangCRFAdministratISOCodeOTH Recommended CDE
3 Context type  The context to which the questions were answered ContextType Recommended CDE
4 Context type other text  The free-text related to ContextType specifying other text ContextTypeOTH Recommended CDE
5 Data source  Source of the data provided on the case report form DataSource Recommended CDE
6 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

PedsQL Family Information Form Impact Scale (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Relationship child type  The type of the family member's relationship to the child, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFRelationshipChildTyp Recommended CDE
2 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Impact scale chronic health condition indicator  Indicates whether or not the child has had a chronic health condition in the last 6 months, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form.. PedsQLFIFImSclChrncHlthCndInd Recommended CDE
3 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Impact scale chronic health condition text  The free-text field to capture the name of the chronic health condition, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFImSclChrncHlthCndTxt Recommended CDE
4 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Impact scale overnight hospital visit indicator  Indicates an overnight visit to the hospital, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFImSclOvnHospVisitInd Recommended CDE
5 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Impact scale overnight hospital visit count  Count of how many overnight hospital visits, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFImSclOvnHospVisitCt Recommended CDE
6 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Impact scale overnight hospital visit text  The free-text field to capture the name of the illness that caused overnight hospital visit, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFImSclOvnHospVisitTxt Recommended CDE
7 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Impact scale emergency room urgent care visit indicator  Indicates whether or not the child visited the emergency room or urgent care, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFImSclERUrCaVisitInd Recommended CDE
8 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Impact scale emergency room urgent care visit count  Count of how many time the child visited the emergency room/urgent care facility, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFImSclERUrCaVisitCt Recommended CDE
9 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Impact scale emergency room urgent care visit text  Text to describe what was wrong with the child when he or she visted the emergency room/urgent care facility, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFImSclERUrCaVisitTxt Recommended CDE
10 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Impact scale miss school count  Count of the number of days the child had to miss school because of a physical injury/ailment, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFImScMissSchoolCt Recommended CDE
11 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Impact scale sick bed count  Count of how many days the child was sick in bed, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFImScSickBedCt Recommended CDE
12 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Impact scale child care count  Count of the number of days the child had to have someone take care of him or her due to a physical or mental health problem, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFImScChildCareCt Recommended CDE
13 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Missed work count  Count of the number of days the parent has missed work due to his or her child's illness, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFMissedWorkCt Recommended CDE
14 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Chid health interfered work scale  Scale of how often the child's health has interfered with the parent's daily routine at work, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFChldHlthInterfWrkScl Recommended CDE
15 Pediatric Quality of Life Inventory (PedsQL) Family Information Form - Child health interfered concentration scale  Scale of how often the child's illness has affected the parent's ability to concentrate on work, as a part of the Pediatric Quality of Life Inventory (PedsQL) Family Information Form. PedsQLFIFChldHlthIntrCntrtnScl Recommended CDE

 Change History

 Administrative Change History