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

 General Details

Title:
UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1)
Short Name:
UCLAPTSDDSMIV
Description:
UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1) Copyright: Robert Pynoos, M.D., Ned Rodriguez, Ph.D., Alan Steinberg, Ph.D., Margaret Stuber, M.D., Calvin Frederick, M.D.. (1998) UCLA PTSD Reaction Index for DSM IV. UCLA Trauma Psychiatry Service. References: Steinberg, A., Brymer, M., Decker, K., and Pynoos, R. (2004). The University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psychiatry Rep 6, 96- 100. Pynoos, R., Rodriguez, N., Steinberg, A., Stuber, M., & Frederick, C. (1998). UCLA PTSD Index for DSM-IV.
Disease:
Traumatic Brain Injury
Organization:
FITBIR
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2016-10-17
Owner:
Number of Data Elements:
68
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

Scary Dangerous Violent Event (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 UCLA PTSD Index for the DSM-IV Child Version - Earthquake indicator 

(Draft)

Indicates whether or not you were in a big earthquake that badly damaged the building you were in, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVEarthquakeInd Recommended UDE
2 UCLA PTSD Index for the DSM-IV Child Version - Another disaster indicator 

(Draft)

Indicates whether or not you were in a big earthquake that badly damaged the building you were in, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVAnthrDisasterInd Recommended UDE
3 UCLA PTSD Index for the DSM-IV Child Version - Bad accident indicator 

(Draft)

Indicates whether or not you were in a bad accident, like a very serious car accident, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVBadAccidtInd Recommended UDE
4 UCLA PTSD Index for the DSM-IV Child Version - War indicator 

(Draft)

Indicates whether or not you were in place where a war was going on around you, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVWarInd Recommended UDE
5 UCLA PTSD Index for the DSM-IV Child Version - Hit punched kicked indicator 

(Draft)

Indicates whether or not you were hit, punched, or kicked very hard at home, not including ordinary fights between brothers & sisters, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVHitPunchdKickdInd Recommended UDE
6 UCLA PTSD Index for the DSM-IV Child Version - Family being hit indicator 

(Draft)

Indicates whether or not you saw a family member being hit, punched or kicked very hard at home, not including ordinary fights between brothers & sisters, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVFmlyBeingHitInd Recommended UDE
7 UCLA PTSD Index for the DSM-IV Child Version - Beaten up indicator 

(Draft)

Indicates whether or not you were beaten up, shot at or threatened to be hurt badly in your town, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVBeatenUpInd Recommended UDE
8 UCLA PTSD Index for the DSM-IV Child Version - Someone beaten up indicator 

(Draft)

Indicates whether or not you saw someone in your town being beaten up, shot at or killed, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVSmeoneBeatenUpInd Recommended UDE
9 UCLA PTSD Index for the DSM-IV Child Version - Dead body indicator 

(Draft)

Indicates whether or not you saw a dead body in your town, not including funerals, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVDeadBodyInd Recommended UDE
10 UCLA PTSD Index for the DSM-IV Child Version - Private sexual body parts indicator 

(Draft)

Indicates whether or not an adult or someone much older had touched your private sexual body parts when you did not want them to, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVPrvteSxBodyPtsInd Recommended UDE
11 UCLA PTSD Index for the DSM-IV Child Version - Violent death indicator 

(Draft)

Indicates whether or not you heard about the violent death or serious injury of a loved one, as part of UCLA PTSD Index for DSM-IV, Child version, revision 2 UCLAPTSDDSMIVViolentDeathInd Recommended UDE
12 UCLA PTSD Index for the DSM-IV Child Version - Painful scary medical treatment indicator 

(Draft)

Indicates whether or not you had painful and scary medical treatment in a hospital when you were very sick or badly injured, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVPnflScryMedTrtInd Recommended UDE
13 UCLA PTSD Index for the DSM-IV Child Version - Anything else scary indicator 

(Draft)

Indicates whether or not OTHER than the situations described above, ANYTHING ELSE has ever happened to you that was REALLY SCARY, DANGEROUS, OR VIOLENT, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVAythnElseScaryInd Recommended UDE
14 UCLA PTSD Index for the DSM-IV Child Version - Yes number 

(Draft)

Question numbers that you answered yes to, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVYesNum Recommended UDE
15 UCLA PTSD Index for the DSM-IV Child Version - Bother the most number 

(Draft)

Question numbers of the thing that bothers you the most now if you answered yes to more than one thing, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVBothrTheMostNum Recommended UDE
16 UCLA PTSD Index for the DSM-IV Child Version - Bad thing happen duration 

(Draft)

Duration of the bad thing happening to you, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVBadThingHappnDur Recommended UDE
17 UCLA PTSD Index for the DSM-IV Child Version - Bad thing happen text 

(Draft)

Description of the bad thing happening to you, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVBadThingHappnTxt Recommended UDE

After Q14 being answered (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 UCLA PTSD Index for the DSM-IV Child Version - Scared dying text 

(Draft)

Indicates whether or not you were scared that you would die during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVScaredDynInd Recommended UDE
2 UCLA PTSD Index for the DSM-IV Child Version - Scared hurt badly indicator 

(Draft)

Indicates whether or not you were scared that you would be hurt badly during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVScaredHrtBdlyInd Recommended UDE
3 UCLA PTSD Index for the DSM-IV Child Version - Hurt badly indicator 

(Draft)

Indicates whether or not you were hurt badly during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVHrtBdlyInd Recommended UDE
4 UCLA PTSD Index for the DSM-IV Child Version - Scared others dying indicator 

(Draft)

Indicates whether or not you were scared that someone else would die during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVScaredOthrsDynInd Recommended UDE
5 UCLA PTSD Index for the DSM-IV Child Version - Scared others hurt badly indicator 

(Draft)

Indicates whether or not you were scared that someone else would be hurt badly during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVScrdOtrsHtBdlyInd Recommended UDE
6 UCLA PTSD Index for the DSM-IV Child Version - Others hurt badly indicator 

(Draft)

Indicates whether or not you felt someone else was hurt badly during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVOthrsHrtBdlyInd Recommended UDE
7 UCLA PTSD Index for the DSM-IV Child Version - Someone die indicator 

(Draft)

Indicates whether or not you felt someone died during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVSomeoneDieInd Recommended UDE
8 UCLA PTSD Index for the DSM-IV Child Version - Scary experiences indicator 

(Draft)

Indicates whether or not you felt very scared, like this was one of your most scary experiences ever during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVScaryExpInd Recommended UDE
9 UCLA PTSD Index for the DSM-IV Child Version - Could not stop what was happening indicator 

(Draft)

Indicates whether or not you felt that you could not stop what was happening or that you needed someone to help during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVCdNtStopWtHapnInd Recommended UDE
10 UCLA PTSD Index for the DSM-IV Child Version - Disgusting gross things indicator 

(Draft)

Indicates whether or not you felt that what you saw was disgusting or gross during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVDisgstnGrsThgsInd Recommended UDE
11 UCLA PTSD Index for the DSM-IV Child Version - Acting upset indicator 

(Draft)

Indicates whether or not you ran around or acted like you were very upset during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVActingUpsetInd Recommended UDE
12 UCLA PTSD Index for the DSM-IV Child Version - Confused indicator 

(Draft)

Indicates whether or not you ran around or acted like you were very upset during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVConfusedInd Recommended UDE
13 UCLA PTSD Index for the DSM-IV Child Version - What happened unreal indicator 

(Draft)

Indicates whether or not you felt what was happening did not seem real in some way during or right after the bad thing happened written in question 14, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVWtHappnUnrealInd Recommended UDE

Problems after very bad things happen (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 UCLA PTSD Index for the DSM-IV Child Version - watching for danger frequency  Frequency of watching out for danger or things that you're afraid of (UCLA PTSD-RI for the DSM-IV Adolescent Version: Hyperarousal) UCLAPTSDDSMIVDangerFreq Recommended CDE
2 UCLA PTSD Index for the DSM-IV Child Version - upset when reminded of event frequency  Frequency of getting very upset, afraid, or sad, when something reminds you of what happened (UCLA PTSD-RI for the DSM-IV Adolescent Version: Reexperiencing) UCLAPTSDDSMIVUpstRmFreq Recommended CDE
3 UCLA PTSD Index for the DSM-IV Child Version - unwanted thoughts of event frequency  Frequency of having upsetting thoughts, pictures, or sounds of what happened come into your mind when you do not want them to (UCLA PTSD-RI for the DSM-IV Adolescent Version: Reexperiencing) UCLAPTSDDSMIVUnwantFreq Recommended CDE
4 UCLA PTSD Index for the DSM-IV Child Version - feeling grouchy, angry, or mad frequency  Frequency of feeling grouchy, angry, or mad (UCLA PTSD-RI for the DSM-IV Adolescent Version: Hyperarousal) UCLAPTSDDSMIVAngryFreq Recommended CDE
5 UCLA PTSD Index for the DSM-IV Child Version - have bad dreams of event frequency  Frequency of having dreams about what happened or other bad dreams (UCLA PTSD-RI for the DSM-IV Adolescent Version: Reexperiencing) UCLAPTSDDSMIVBdDrmsFreq Recommended CDE
6 UCLA PTSD Index for the DSM-IV Child Version - flashback to event frequency  Frequency of feeling like you are back at the time when the bad thing happened, living through it again (UCLA PTSD-RI for the DSM-IV Adolescent Version: Reexperiencing) UCLAPTSDDSMIVFlshbkFreq Recommended CDE
7 UCLA PTSD Index for the DSM-IV Child Version - feeling antisocial frequency  Frequency of problems with feeling like staying by yourself and not being with your friends (UCLA PTSD-RI for the DSM-IV Adolescent Version: Emotional Numbing) UCLAPTSDDSMIVAntisoFreq Recommended CDE
8 UCLA PTSD Index for the DSM-IV Child Version - feeling alone inside frequency  Frequency of feeling alone inside and not close to other people (UCLA PTSD-RI for the DSM-IV Adolescent Version: Emotional Numbing) UCLAPTSDDSMIVFeelAlFreq Recommended CDE
9 UCLA PTSD Index Child Version - trying not to think about event frequency  Frequency of trying not to talk about, think about, or have feelings about what happened (UCLA PTSD-RI for the DSM-IV Adolescent Version: Avoidance) UCLAPTSDDSMIVAvdThkFreq Recommended CDE
10 UCLA PTSD Index for the DSM-IV Child Version - trouble feeling happiness or love frequency  Frequency of having trouble feeling happiness or love (UCLA PTSD-RI for the DSM-IV Adolescent Version: Emotional Numbing) UCLAPTSDDSMIVTrHappFreq Recommended CDE
11 UCLA PTSD Index for the DSM-IV Child Version - trouble feeling sadness or anger frequency  Frequency of having trouble feeling sadness or anger (UCLA PTSD-RI for the DSM-IV Adolescent Version: Emotional Numbing) UCLAPTSDDSMIVTrSadFreq Recommended CDE
12 UCLA PTSD Index for the DSM-IV Child Version - feeling jumpy or startling easily frequency  Frequency of feeling jumpy or startling easily, like when you hear a loud noise or when something surprises you (UCLA PTSD-RI for the DSM-IV Adolescent Version: Hyperarousal) UCLAPTSDDSMIVJumpyFreq Recommended CDE
13 UCLA PTSD Index for the DSM-IV Child Version - trouble sleeping frequency  Frequency of having trouble going to sleep or waking up often during the night (UCLA PTSD-RI for the DSM-IV Adolescent Version: Hyperarousal) UCLAPTSDSleepFreq Recommended CDE
14 UCLA PTSD Index for the DSM-IV Child Version - blaming self frequency  Frequency of thinking that some part of what happened is your fault (UCLA PTSD-RI for the DSM-IV Adolescent Version: Associative Symptoms) UCLAPTSDDSMIVBlameFreq Recommended CDE
15 UCLA PTSD Index for the DSM-IV Child Version - trouble remembering event frequency  Frequency of having trouble remembering important parts of what happened (UCLA PTSD-RI for the DSM-IV Adolescent Version: Emotional Numbing) UCLAPTSDDSMIVTrEvenFreq Recommended CDE
16 UCLA PTSD Index for the DSM-IV Child Version - trouble concentrating frequency  Frequency of having trouble concentrating or paying attention (UCLA PTSD-RI for the DSM-IV Adolescent Version: Hyperarousal) UCLAPTSDDSMIVTroubCFreq Recommended CDE
17 UCLA PTSD Index for the DSM-IV Child Version - avoiding reminders of event frequency  Frequency of trying to stay away from people, places, or things that make you remember what happened (UCLA PTSD-RI for the DSM-IV Adolescent Version: Avoidance) UCLAPTSDDSMIVAvoidFreq Recommended CDE
18 UCLA PTSD Index for the DSM-IV Child Version - strong feelings in body when reminded of event frequency  Frequency of having strong feelings in your body, like your heart beats fast, your head aches, or your stomach aches, when something reminds you of what happened (UCLA PTSD-RI for the DSM-IV Adolescent Version: Reexperiencing) UCLAPTSDDSMIVPhyRctFreq Recommended CDE
19 UCLA PTSD Index for the DSM-IV Child Version - thinking life will be short frequency  Frequency of thinking you will not live a long life (UCLA PTSD-RI for the DSM-IV Adolescent Version: Emotional Numbing) UCLAPTSDDSMIVShortFreq Recommended CDE
20 UCLA PTSD Index for the DSM-IV Child Version - afraid event will reoccur frequency  Frequency of being afraid that the bad thing will happen again (UCLA PTSD-RI for the DSM-IV Adolescent Version: Associative Symptoms) UCLAPTSDDSMIVAfraidFreq Recommended CDE

Frequency rating sheet (Appears Up To 1 Time)

# Title Short Description Variable Name Required? Type
1 UCLA PTSD Index for the DSM-IV Child Version - How much happen grade 

(Draft)

How much of the time for the problems that happened during the past month, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVHowMuchHappnGrade Recommended UDE
2 UCLA PTSD Index for the DSM-IV Child Version - Problem happen start date 

(Draft)

Start date for the problems that happened during the past month, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVProbHapnStartDate Recommended UDE
3 UCLA PTSD Index for the DSM-IV Child Version - How often happen frequency 

(Draft)

How often of the time for the problems that happened during the past month, as part of UCLA PTSD Index for DSM-IV, Child version, revision 1 UCLAPTSDDSMIVHowOftenHappnFreq Recommended UDE

 Change History

 Administrative Change History