Form Structure: FITBIR Demographics Form
This form structure is an organized set of data definitions for a form that has not been copyrighted
Title:
FITBIR Demographics Form
Short Name:
DemogrFITBIR
Description:
FITBIR Demographics standard form
Disease:
Traumatic Brain Injury
Required Program Form:
Yes
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Publication Date:
2018-01-31
Version:
1.0
Date Created:
2018-01-30
Owner:
Number of Data Elements:
137
eForms:
Y
Logically grouped data elements with defined frequency at which they repeat.
Additional Element Groups
Listed below are your additional element groups.
Main Group (Appears Exactly 1 Time)
# | 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 | Required | CDE |
4 | Visit date | Actual interview or visit date | VisitDate | Recommended | CDE |
5 | Site name | The name of the site for the study | SiteName | Recommended | CDE |
6 | Days since baseline | The number of days since baseline | DaysSinceBaseline | Optional | CDE |
7 | Case control indicator | Indicator of whether subject is in the case or control arm of the study. | CaseContrlInd | Optional | CDE |
8 | General notes text | General notes | GeneralNotesTxt | Optional | CDE |
Form Administration (Appears Up To 1 Time)
# | 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 |
Subject Demographics (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Birth date | Date (and time, if applicable and known) the participant/subject was born | BirthDate | Optional | CDE |
2 | Gender Type | Self-reported gender of the participant/subject. Gender is the socially constructed identity of sex. | GenderTyp | Recommended | CDE |
3 | Sex participant or subject genotype type | Sex chromosomes of the participant/subject based upon genotyping | SexSubjectGenotypTyp | Recommended | CDE |
4 | Sex participant or subject genotype other text | The free-text field related to Sex participant or subject genotype type specifying other text. Sex chromosomes of the participant/subject based upon genotyping | SexSubjectGenotypOTH | Recommended | CDE |
5 | Hand preference type | Hand which the participant/subject uses predominantly, not necessarily the hand he/she writes with exclusively. | HandPrefTyp | Recommended | CDE |
6 | Race USA category | The subject self declared racial origination, independent of ethnic origination, using OMB approved categories. | RaceUSACat | Recommended | CDE |
7 | Race category | Category of race(s) or region(s) the participant/subject most closely identifies with | RaceCat | Recommended | CDE |
8 | Ethnicity USA category | Category of ethnicity the participant/subject most closely identifies with | EthnUSACat | Recommended | CDE |
9 | Ethnicity category | The free-text field describing the category of ethnicity the participant/subject most closely identifies with. | EthnCatTxt | Recommended | CDE |
Subject Country of Birth and Current Residency (Appears Up To 5 Times)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Birth country ISO code | Code (ISO 3166-1 alpha-2 code) for country where the participant/subject was born | BirthCntryISOCode | Recommended | CDE |
2 | Birth country name | Name for country where the participant/subject was born | BirthCntryName | Recommended | CDE |
3 | Country of residence ISO code | Code (ISO 3166-1 alpha-2) for the country where the participant/subject currently lives. | CntryResdnceISOCode | Recommended | CDE |
4 | Country of residence name | Name of the country where the participant/subject currently lives. | CntryResdnceName | Recommended | CDE |
Subject Language (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Language primary ISO code | Code (ISO 639-2 alpha-3 code) for the language the participant/subject speaks most often. | LangPrimryTxt | Recommended | CDE |
2 | Language primary other text | The free-text field related to Language primary text specifying other text. Text for the language the participant/subject speaks most often | LangPrimryOTH | Recommended | CDE |
3 | Language spoken fluent code | Code (ISO 639-2)for each language that the participant/subject speaks fluently | LangSpokeFluentISOCode | Recommended | CDE |
4 | Language spoken Fluent text | Text for each language that the participant/subject speaks fluently | LangSpokeFluentTxt | Recommended | CDE |
5 | Language written fluent ISO code | Code (ISO 639-2) for each language that the participant/subject writes fluently | LandWrtnFlntlyISOCode | Recommended | CDE |
6 | Language written fluent text | Text for each language that the participant/subject writes fluently | LangWrtnFlntlyTxt | Recommended | CDE |
Subject Marital Status (Appears Up To 5 Times)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Marital or partner status | Status of participant/subjects current domestic relationship, whether marital or partnered | MartlPartnerStatus | Recommended | CDE |
2 | Marital or partner status other text | The free-text field related to Marital or partner status specifying other text. Status of participant/subjects current domestic relationships. | MartlPartnerStatusOTH | Recommended | CDE |
Subject Living Situation (Appears Up To 5 Times)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Living situation of an adult subject | Living situation of an adult subject, including the primary person living with adult subject information | SesPrimAdult | Recommended | CDE |
2 | Other primary person living with adult patient | Other Primary person living with adult patient | SesPrimAdultOther | Recommended | CDE |
3 | Living situation of juvenile patient | Living situation of juvenile patient | SesPrimChild | Recommended | UDE |
4 | Living situation of juvenile patient other text | Living situation of juvenile patient other text | SesPrimChildOTH | Recommended | UDE |
5 | Living situation before injury type | Living situation of the participant/subject before injury. | LivingSituationPreInjTyp | Recommended | CDE |
6 | Living situation before injury type, specifying other text | The free-text related to "LivingSituationPreInjTyp" specifying other text. | LivingSituationPreInjTypOTH | Recommended | CDE |
7 | Subject cohabitants count | Count of other people with whom the participant/subject currently lives, cohabits, or stays | SubjectCohabitCt | Recommended | CDE |
8 | Dependent children living in household number | Number of dependent children living in household | DpndntChildLvngHshldNum | Recommended | CDE |
9 | Number of dependent children | Number of dependent children for a participant/subject | DependentChildNum | Recommended | CDE |
10 | Residence area type | Type describing the participant's/subjects current location of residence | ResidenceAreaTyp | Recommended | CDE |
11 | Residence type | Type of residence where the participant/subject is currently living | ResdncTyp | Recommended | CDE |
12 | Residence other text | The free-text field related to Residence type specifying other text. Type of residence where the participant/subject is currently living | ResdncOTH | Recommended | CDE |
Subject Family Income (Appears Up To 1 Time)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Family income range | Range, in U.S. dollars, of the annual pre-tax, pre-deduction total income, of the household of which the participant/subject is a member | FmlyIncRange | Recommended | CDE |
2 | Family income supported persons count | Count of all people, including the participant/subject, who are supported by the household gross annual income reported | FamilyIncmeSupprtPersCt | Recommended | CDE |
3 | Family income value | Value, in U.S. dollars, of the annual pre-tax, pre-deduction total income, of the household of which the participant/subject is a member | FamilyIncmeVal | Recommended | CDE |
4 | Household wage earners number | Number of wage earners in household | HshldWgeEarnNum | Recommended | CDE |
5 | Income basic needs status | The status of how the household currently manages to meet basic needs as defined by food, shelter and clothing. | IncomeBasicNeedsStatus | Recommended | CDE |
Subject Education (Appears Up To 3 Times)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Education level USA type | Highest grade or level of school participant/subject has completed or the highest degree received | EduLvlUSATyp | Recommended | CDE |
2 | Education level USA type other text | The free-text field related to Education level USA type, specifying other text. The highest level of education the participant/subject received. | EduLvlUSATypOTH | Recommended | CDE |
3 | Education type | The type of education the participant/subject received. | EduTyp | Recommended | CDE |
4 | Education other text | The free-text field related to Education type specifying other text. The type of education the participant/subject received. | EduOTH | Recommended | CDE |
5 | Education year count | Number of years of education completed (age 5 and beyond) | EduYrCt | Recommended | CDE |
6 | Highest level education pre-injury | Highest level education pre-injury | HighestLvlEduPreInj | Recommended | UDE |
7 | Education school participation status | Status of participant/subjects current attendance at school | EduSchoolParticipStatus | Recommended | CDE |
8 | School placement type | The description of the type of education the participant/subject receives with details of being with or without assistance. | SchoolPlacementTyp | Recommended | CDE |
9 | School placement other text | The free-text field related to 'School placement type' specifying other text. The description of the type of education the participant/subject receives with details of being with or without assistance. | SchoolPlacementOTH | Recommended | CDE |
Subject Occupation and Employment (Appears Up To 10 Times)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Occupation primary status | The status indicating the participant's/subjects current primary occupational status. | OccupationPrimaryStatus | Recommended | CDE |
2 | Occupation primary status other text | The free-text field to capture other status indicating the participant's/subjects current primary occupational status. | OccupationPrimaryStatusOTH | Recommended | CDE |
3 | Employment expanded status | Status of participant/subjects current employment | EmplmtExpndStatus | Recommended | CDE |
4 | Employment expanded other text | The free-text field related to Employment expanded status specifying other text. Status of participant/subjects current employment | EmplmtExpndOTH | Recommended | CDE |
5 | Job classification pre-injury | Job classification pre-injury | JobClassPreInj | Recommended | UDE |
6 | Job classification pre-injury other text | The free-text field related to Job classification pre-injury specifying other text. | JobClassPreInjOTH | Recommended | UDE |
7 | Job classification-now | Job classification-now | JobClassNow | Recommended | UDE |
8 | Job classification-now other text | The free-text field related to Job classification-now specifying other text. | JobClassNowOTH | Recommended | UDE |
9 | Unemployed reason | Participant/subject reason for unemployment | UnemplymntRsn | Recommended | CDE |
Parent Guardian or Caregiver Information (Appears Up To 6 Times)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Primary caregiver extended type | Type of relationship between the person who acts as the primary caregiver for the participant/subject and the participant/subject | CaregvPrimryExtendType | Recommended | UDE |
2 | Primary caregiver extended type other text | The free-text field related to Primary caregiver extended type. | CaregvPrimryExtendOTH | Recommended | UDE |
3 | Alive status of subjects parents | Specifies whether the participant's/subjects parents are still living | ParentAliveStatus | Recommended | UDE |
4 | Gender Type | Self-reported gender of the participant/subject. Gender is the socially constructed identity of sex. | GenderTyp | Recommended | CDE |
5 | Race USA category | The subject self declared racial origination, independent of ethnic origination, using OMB approved categories. | RaceUSACat | Recommended | CDE |
6 | Race category | Category of race(s) or region(s) the participant/subject most closely identifies with | RaceCat | Recommended | CDE |
7 | Ethnicity USA category | Category of ethnicity the participant/subject most closely identifies with | EthnUSACat | Recommended | CDE |
8 | Ethnicity category | The free-text field describing the category of ethnicity the participant/subject most closely identifies with. | EthnCatTxt | Recommended | CDE |
9 | Birth country ISO code | Code (ISO 3166-1 alpha-2 code) for country where the participant/subject was born | BirthCntryISOCode | Recommended | CDE |
10 | Birth country name | Name for country where the participant/subject was born | BirthCntryName | Recommended | CDE |
11 | Marital or partner status | Status of participant/subjects current domestic relationship, whether marital or partnered | MartlPartnerStatus | Recommended | CDE |
12 | Dependent children living in household number | Number of dependent children living in household | DpndntChildLvngHshldNum | Recommended | CDE |
13 | Number of dependent children | Number of dependent children for a participant/subject | DependentChildNum | Recommended | CDE |
14 | Residence area type | Type describing the participant's/subjects current location of residence | ResidenceAreaTyp | Recommended | CDE |
15 | Residence type | Type of residence where the participant/subject is currently living | ResdncTyp | Recommended | CDE |
16 | Residence other text | The free-text field related to Residence type specifying other text. Type of residence where the participant/subject is currently living | ResdncOTH | Recommended | CDE |
17 | Education level primary caregiver USA type | Highest grade or level of school the participant's/subject's primary caregiver has completed or the highest degree he/she has received | EduLvlPrimCaregiverUSATyp | Recommended | CDE |
18 | Education primary caregiver year count | Number of years of education of the primary caregiver (age 5 and beyond). | EduPrimCaregiverYrCt | Recommended | CDE |
19 | Occupation primary status | The status indicating the participant's/subjects current primary occupational status. | OccupationPrimaryStatus | Recommended | CDE |
20 | Occupation primary status other text | The free-text field to capture other status indicating the participant's/subjects current primary occupational status. | OccupationPrimaryStatusOTH | Recommended | CDE |
21 | Job classification category | Category that classifies work performed by participant/subject. | JobclassCat | Recommended | CDE |
22 | Employment expanded status | Status of participant/subjects current employment | EmplmtExpndStatus | Recommended | CDE |
23 | Employment expanded other text | The free-text field related to Employment expanded status specifying other text. Status of participant/subjects current employment | EmplmtExpndOTH | Recommended | CDE |
24 | Unemployed reason | Participant/subject reason for unemployment | UnemplymntRsn | Recommended | CDE |
25 | Family income range | Range, in U.S. dollars, of the annual pre-tax, pre-deduction total income, of the household of which the participant/subject is a member | FmlyIncRange | Recommended | CDE |
26 | Family income value | Value, in U.S. dollars, of the annual pre-tax, pre-deduction total income, of the household of which the participant/subject is a member | FamilyIncmeVal | Recommended | CDE |
27 | Family income supported persons count | Count of all people, including the participant/subject, who are supported by the household gross annual income reported | FamilyIncmeSupprtPersCt | Recommended | CDE |
Subject Military Status (Appears Up To 3 Times)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Active military status indicator | Whether participant currently has active military status | MilActiveInd | Recommended | UDE |
2 | Military occupational status of participant | Military occupational status of participant | MilMOS | Optional | UDE |
3 | Military occupational status of participant other text | Military occupational status of participant other text | MilMOSOTH | Optional | UDE |
4 | Military USA service branch type | Branch of service in the U.S. military, not including the Commissioned Corps | MilUSAServBrnchTyp | Optional | CDE |
5 | Military USA service branch other text | The free-text field related to Military USA service branch type specifying other text. Branch of service in the U.S. military, not including the Commissioned Corps | MilUSAServBrnchOTH | Optional | CDE |
6 | Military rank category | Category that describes the participant's/subjects rank in the military | MilRnkCat | Optional | CDE |
7 | Military rank category other text | The free-text field related to Military rank category specifying other text. Category that describes the participant's/subjects rank in the military | MilRnkCatOTH | Optional | UDE |
8 | To where the military patient was deployed | Region or country the military patient was deployed | MilDeploy | Optional | UDE |
9 | To where the military patient was deployed other text | Region or country to where the military patient was deployed other text | MilDeployOTH | Optional | UDE |
Subject Involvement in Sports (Appears Up To 10 Times)
# | Title | Short Description | Variable Name | Required? | Type |
---|---|---|---|---|---|
1 | Injury from sports indicator | TBI Screen: Injured head/neck doing sports | TBISportInd | Optional | UDE |
2 | Sport(s) participation in elementary school indicator | Whether subject participated in sport(s) in elementary school | ElementarySchoolSprtInd | Optional | UDE |
3 | Primary elementary school sport played | The primary sport the participant played in elementary school | ElementarySchoolPrimaryPlayed | Optional | UDE |
4 | Years played sports elementary school number | Number of years subject played sport(s) in elementary school | ElementarPrimarySprtYrsNum | Optional | UDE |
5 | Other sports subject played in elementary school | Which other sports the participant played in elementary school | ElementarySchoolSportOthrPlayd | Optional | UDE |
6 | Total combined years the participant played other elementary school sport(s) | Total combined number of years the participant played other sport(s) in elementary school | ElementarySchoolSportOtherYrs | Optional | UDE |
7 | Sport(s) participation in junior high school indicator | Whether subject played sports in junior high school | JuniorHighSchoolSportInd | Optional | UDE |
8 | Primary sport subject played in junior high school | Which sports subject played in junior high school | JuniorHighPrimarySportPlayed | Optional | UDE |
9 | Years played sports junior high school number | Number of years subject played sport(s) in junior high school | JuniorHighPrimarySprtYrsNum | Optional | UDE |
10 | Other sports subject played in Junior high school | Which sports subject played inJunior high school | JuniorHighSportOtherplayed | Optional | UDE |
11 | Total combined years the participant played other junior high school sport(s) | Total combined number of years subject played sport(s) junior high school | JuniorHighSportOtherYrs | Optional | UDE |
12 | Sport(s) participation in high school indicator | Whether subject played sports in high school | HighSchoolSportInd | Optional | UDE |
13 | Primary high school sport played | The primary sport the participant played in high school | HighSchoolSportPrimaryplayed | Optional | UDE |
14 | Years played primary high school sport number | Number of years subject played sport(s) in high school | HighSchoolPrimarySportYears | Optional | UDE |
15 | Other sports subject played in high school | Which sports subject played in high school | HighSchoolSportOtherplayed | Optional | UDE |
16 | Total combined years the participant played other high school sport(s) | Total combined number of years participant played other sport(s) in high school | HighSchoolSportOtherYears | Optional | UDE |
17 | Sport(s) participation in college indicator | Indicator whether the participant played sports in college. | CollegeSportInd | Optional | UDE |
18 | Primary college sport played by the participant | The primary sport the participant played in college. | CollegeSportPrimaryPlayed | Optional | UDE |
19 | Total combined years the partisipant played primary college sport | Total combined years the partisipant played primary college sport. | CollegeSportPrimaryYears | Optional | UDE |
20 | Other sport(s) the participant played in college | Other sports the participant played in college. A complimentary UDE for "Primary college sport played by the participant". | CollegeSportPlayedOTH | Optional | UDE |
21 | College sport other played | College sports played other than primary sport | CollegeSportOtherPlayed | Optional | UDE |
22 | Total combined years the partisipant played other college sport(s) | Total combined years the partisipant played other college sport(s). | CollegeSportOtherYears | Optional | UDE |
23 | Recreational sport(s) participation indicator | Whether the participant played recreational sports | RecreationallSportInd | Optional | UDE |
24 | Primary recreational sport played by the participant | Which sport the participant primarily played recreationally | RecreationaSportPrimaryPlayed | Optional | UDE |
25 | Total combined years the participant played primary recreational sport | Total number of years the participant played primary sport recreationally | RecreationaSportPrimaryYears | Optional | UDE |
26 | Other recreational sports played by the participant | Which other sport(s) the participant played recreationally | RecreationaSportOtherPlayed | Optional | UDE |
27 | Total combined years the participant played other recreational sport(s) | Total number of years subject played other sport(s) recreationally | RecreationaSportOtherYears | Optional | UDE |
28 | Professional sport(s) participation indicator | Indicator whether the participant played sports professionally. | ProfessionalSportInd | Optional | UDE |
29 | Primary professional sport played by the participant | The primary sport the participant played in college. | ProfessionalSportPrimaryPlayed | Optional | UDE |
30 | Total combined years the partisipant played primary professional sport | Total combined years the participant played primary professional sport (should be used in combination with Primary professional sport played by the participant UDE). | ProfessionalSportPrimaryYears | Optional | UDE |
31 | Other professional sports played by the participant | Other sports the participant played professionally. A complimentary UDE for Primary professional sport played by the participant. | ProfessionalSportPlayedOTH | Optional | UDE |
32 | Professional sport other played | Professional sports played othre than primary sport | ProfessionalSportOtherPlayed | Optional | UDE |
33 | Total combined years the partisipant played other professional sport(s) | Total combined years the participant played other professional sport(s) (should be used in combination with Other professional sports played by the participant. | ProfessionalSportOtherYears | Optional | UDE |
Keywords