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

 General Details

Title:
TBI-QOL Item Bank v1.0-Mobility-Short Form 10a
Short Name:
TBIQOLMobility
Description:
TBI-QOL Mobility is a 10 item short form that assesses an individual's ability to carry out various activities involving the trunk region and increasing degrees of bodily movement, ambulation, balance, or endurance. This instrument includes items from Neuro-QOL Adult Bank Lower Extremity Function. Tulsky, D. S., Kisala, P. A., Victorson, D., Carlozzi, N., Bushnik, T., Sherer, M., & Englander, J. (2016). TBI-QOL: development and calibration of item banks to measure patient reported outcomes following traumatic brain injury.The Journal of head trauma rehabilitation, 31(1), 40. TBI-QOL Items Copyright 2015 David Tulsky and Kessler Foundation. All rights reserved. http://www.assessmentcenter.net/ Recommended by CDISC for TBI
Disease:
Traumatic Brain Injury
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-06-02
Owner:
Number of Data Elements:
28
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 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

TBI-QOL Mobility (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 Quality of Life - Movement armless straight chair stand up difficulty scale  The scale which represents the amount of difficulty the participant currently has in standing up from an armless straight chair (e.g., dining room chair), as part of Neuro-QOL Lower Extremity Function. QoLMoveArmlssStrghtChrAbltyScl Recommended CDE
2 Quality of Life - Movement flight stair handrail up down difficulty scale  The scale which represents the amount of difficulty the participant currently has in going up and down a flight of stairs inside, using a handrail, as part of Neuro-QOL Lower Extremity Function. QolMoveFlghtStrUpDwnDiffScl Recommended CDE
3 Quality of Life - Movement uneven surface walk difficulty scale  The scale which represents the amount of difficulty the participant currently has in walking on uneven surfaces (e.g., grass, dirt road or sidewalk), as part of Neuro-QOL Lower Extremity Function. QolMoveUnevenSrfaceWlkDiffScl Recommended CDE
4 Quality of Life - Movement single floor walk difficulty scale  The scale which represents the amount of difficulty the participant currently has in walking around one floor of their home, as part of Neuro-QOL Lower Extremity Function. QolMoveSingleFloorWalkDiffScl Recommended CDE
5 Quality of Life - Movement no handrail stair climb difficulty scale  The scale which represents the amount of difficulty the participant currently has in climbing stairs step over step without a handrail (alternating feet), as part of Neuro-QOL Lower Extremity Function. QoLMoveNoHandrlStrClmbDiffScl Recommended CDE
6 TBI Quality of Life (TBI-QOL) - Difficulty going up and down three flights of stairs scale  The scale representing how much difficulty the participant currently has going up and down three flights of stairs inside. TBIQOLDiffcltyUpDwnThreeStrScl Recommended CDE
7 TBI Quality of Life (TBI-QOL) - Difficulty walking in a busy place without losing balance scale  The scale representing how much difficulty the participant currently have walking in a busy place without losing their balance. TBIQOLDiffcltyWalkngBsyPlceScl Recommended CDE
8 Quality of Life - Movement walk fifteen minute duration ability scale  The scale which represents the extent to which the participant was able to go for a walk of at least 15 minutes, as part of Neuro-QOL Lower Extremity Function. QolMoveWlkFftnMinDurAbltyScl Recommended CDE
9 Quality of Life - Movement up down step curb ability scale  The scale which represents the extent to which the participant was able to step up and down curbs, as part of Neuro-QOL Lower Extremity Function. QolMoveUpDownStepCurbAbltyScl Recommended CDE
10 Quality of Life - Movement in out car ability scale  The scale which represents the extent to which the participant was able to get in and out of the car, as part of Neuro-QOL Lower Extremity Function. QolMoveInOutCarAbilityScl Recommended CDE

TBI-QOL Mobility Scoring (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 TBI Quality of Life (TBI-QOL) - Mobility raw score  The raw score for TBI-QOL Mobility. TBIQOLMobilityRawScore Recommended CDE
2 TBI Quality of Life (TBI-QOL) - Mobility T-score  The T-Score related to ability to carry out various activities involving the trunk region and increasing degrees of bodily movement, ambulation, balance, or endurance. TBIQOLMobTScore Recommended CDE
3 TBI-Quality of Life (TBI-QOL) - Standard error  Standard error, as part of TBI-Quality of Life (TBI-QOL) measures TBIQOLStandardError Recommended CDE

 Change History

 Administrative Change History