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 - Upper Extremity - Short Form 9a
Short Name:
TBIQOLUpperExtremity
Description:
TBI-QOL Upper Extremity includes 9 items that assess the ability to carry out various activities involving digital, manual, and reach-related functions, ranging from fine motor to self-care (activities of daily living). This short form includes items from PROMIS Upper Extremity and Physical Function, and Neuro-QOL Upper Extremity. 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:
27
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 Upper Extremity (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 TBI Quality of Life (TBI-QOL) -Difficulty applying spreads to bread using a knife scale  The scale representing how much difficulty the participant currently has applying spreads to bread using a knife TBIQOLDiffcltyApplySpdBreadScl Recommended CDE
2 Quality of Life - Movement dress pullover shirt on difficulty scale  The scale which represents the amount of difficulty the participant currently has in putting on a pullover shirt, as part of Neuro-QOL Upper Extremity. QolMoveDrssPllvrShrtAblityScl Recommended CDE
3 TBI- Quality of Life (TBI-QOL)- Difficulty putting band-aid or gauze pad scale  The scale which represents the amount of difficulty the participant currently has putting on a Band-Aid or gauze pad on his/her self. TBIQOLDiffcltyBandAidScl Recommended CDE
4 TBI-Quality of Life (TBI-QOL) - Able to open can with a hand can opener scale  The scale which represents the participants ability to open a can with a hand can opener TBIQOLAbleCanOpenScl Recommended CDE
5 Quality of Life - Movement zipper open close ability scale  The scale which represents the extent to which the participant was able to open and close a zipper, as part of Neuro-QOL Upper Extremity. QoLMoveZipprOpnClseAblityScl Recommended CDE
6 Quality of Life - Movement pick up coin ability scale  The scale which represents the extent to which the participant was able to pick up coins from a table top, as part of Neuro-QOL Upper Extremity. QoLMovePckUpCoinAbltyScl Recommended CDE
7 Quality of Life - Movement full food plate hold ability scale  The scale which represents the extent to which the participant was able to hold a plate full of food, as part of Neuro-QOL Upper Extremity. QolMoveFulFoodPlatHldAbltyScl Recommended CDE
8 Quality of Life - Movement shampoo hair ability scale  The scale which represents the extent to which the participant was able to shampoo their hair, as part of Neuro-QOL Upper Extremity. QoLMoveShampooHairAbilityScl Recommended CDE
9 Quality of Life - Movement fingernail trim ability scale  The scale which represents the extent to which the participant was able to trim their fingernails, as part of Neuro-QOL Upper Extremity. QolMoveFingernlTrimAbiltyScl Recommended CDE

TBI-QOL Upper Extremity Scoring (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 TBI- Quality of Life (TBI-QOL) Upper extremity raw score  The raw score for TBI-QOL Upper Extremity. TBIQOLUEXRawScore Recommended CDE
2 TBI Quality of Life (TBI-QOL) - Upper extremity function T-score  The T-Score related to ability to carry out various activities involving digital, manual, and reach-related functions, ranging from fine motor to self-care (activities of daily living). TBIQOLUEXTScore 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