CDE Detailed Report

Disease: Sport Related Concussion
Subdomain Name: Mood/Anxiety
CRF: content

Displaying 1 - 50 of 127
CDE ID CDE Name Variable Name Definition Short Description Question Text Permissible Values Description Data Type Disease Specific Instructions Disease Specific Reference Population Classification (e.g., Core) Version Number Version Date CRF Name (CRF Module / Guidance) Subdomain Name Domain Name Size Input Restrictions Min Value Max Value Measurement Type External Id Loinc External Id Snomed External Id caDSR External Id CDISC
C55188 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Blame other exaggerated frequency past month grade UCLAPTSDRIDSM5BlOrExFqPsMGrade Grade of frequency during the past month that the subject/participant has exagerratedly blamed others for the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has exagerratedly blamed others for the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I am mad with someone for making the bad thing happen, not doing more to stop it, or to help after 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55097 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Traffic exploit sexual suffer indicator UCLAPTSDRIDSM5TrfcExptSxSfrInd Indicator of whether the subject/participant has ever been trafficked or exploited for labor or sex, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been trafficked or exploited for labor or sex, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Trafficking/Sexual Exploitation: Have you ever done sexual things for money, food, clothes or protection? Were you ever sold to someone to work for them? Have you been forced into prostitution or pornography? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 11:40:46.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55237 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom increase difficulty do important thing peer indicator UCLAPTSDRIDSM5SyInDfDoITPInd Indicator of whether the subject/participant's PTSD symptom(s) cause(s) him or her difficulty in doing important things that his or her peers are doing, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant's PTSD symptom(s) cause(s) him or her difficulty in doing important things that his or her peers are doing, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Do these reactions (thoughts and feelings) make it harder for you to do important things that other kids your age are doing? No;Yes No;Yes Alphanumeric

Clinician: Check whether the reactions (thoughts and feelings) above appear to cause clinically significant distress or functional impairment.s

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 14:25:18.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55139 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Bereavement trauma detail death reason UCLAPTSDRIDSM5BrvmtTrDtlDthRsn The type field for identifying details about the cause of death related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Bereavement, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details about the cause of death related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Bereavement, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Cause of Death Natural Causes;Natural disaster;Accident;Homicide;Suicide;Other Natural Causes (illness, age);Natural disaster;Accident (car, drowning);Homicide;Suicide;Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 15:51:34.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55202 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Affect negative fear frequency past month grade UCLAPTSDRIDSM5AfNgFrFqPMGrade Grade of frequency during the past month that the subject/participant has felt fearful, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has felt fearful, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I feel afraid or scared 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55114 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Violence domestic trauma detail type UCLAPTSDRIDSM5VcDomTrmDtlTyp The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Domestic Violence, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Domestic Violence, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Domestic Violence Trauma Details Witnessed bad fight;Witnessed sexual assault;Threatened harm;Weapon Used;Serious Injury;Report Filed Witnessed bad fight;Witnessed sexual assault;Threatened harm;Weapon Used;Serious Injury;Report Filed Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 14:01:19.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55150 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Bully trauma detail other text UCLAPTSDRIDSM5BullyTrDtlOTH The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Bully trauma detail type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Bully trauma detail type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Bullying Trauma Details Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:03:18.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 30

Free-Form Entry

C55163 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Flashback frequency past month grade UCLAPTSDRIDSM5FlshbFqPsMoGrade Grade of frequency during the past month that the subject/participant has had flashbacks of the trauma or loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has had flashbacks of the trauma or loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I feel like I am back at the time when the bad thing happened, like it's happening all over again. 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55087 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Abuse psychological emotional suffer indicator UCLAPTSDRIDSM5AbsPsyEmoSfrInd Indicator of whether the subject/participant has ever suffered psychological maltreatment or emotional abuse at home or by his or her family, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever suffered psychological maltreatment or emotional abuse at home or by his or her family, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Psychological Maltreatment/Emotional Abuse: Did anyone in your family ever keep telling you that you are no good, keep yelling at you or keep threatening to or send you away? Were you often punished at home in ways that felt very unfair? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 11:00:54.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55227 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause other problem home indicator UCLAPTSDRIDSM5SmCsOthPbHmInd Indicator of whether the subject/participant's PTSD symptom(s) cause problems other than getting into trouble or difficulty getting along at home, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant's PTSD symptom(s) cause problems other than getting into trouble or difficulty getting along at home, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Do these reactions (thoughts and feelings) cause some other problem at home? No;Yes No;Yes Alphanumeric

Clinician: Check whether the reactions (thoughts and feelings) above appear to cause clinically significant distress or functional impairment.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 13:20:54.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55129 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Abuse psychological emotional trauma detail other text UCLAPTSDRIDSM5AbsPsyEmTrDtlOTH The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Abuse psychological emotional trauma detail type' specifying Psychological Maltreatment/Emotional Abuse, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Abuse psychological emotional trauma detail type' specifying Psychological Maltreatment/Emotional Abuse, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM- Psychological Maltreatment/Emotional Abuse Trauma Details Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 15:00:04.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 30

Free-Form Entry

C55189 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Irritable aggressive frequency past month grade UCLAPTSDRIDSM5IrAgFqPsMoGrade Grade of frequency during the past month that the subject/participant has been irritable or aggressive, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has been irritable or aggressive, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I get upset easily or get into arguments or physical fights 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55098 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Suicide attempt indicator UCLAPTSDRIDSM5SuicdAtmptInd Indicator of whether the subject/participant has ever attempted suicide, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever attempted suicide, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Attempted Suicide: Have you ever tried to kill yourself? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 11:43:30.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55238 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause developmental progress other problem indicator UCLAPTSDRIDSM5SyCsDvPgOtPrInd Indicator of whether the subject/participant's PTSD symptom(s) cause(s) problems of developmental progression other than difficulty in doing important things that his or her peers are doing, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant's PTSD symptoms cause problems of developmental progression other than difficulty in doing important things that his or her peers are doing, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Other No;Yes No;Yes Alphanumeric

Clinician: Check whether the reactions (thoughts and feelings) above appear to cause clinically significant distress or functional impairment.s

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 14:25:18.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55140 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Bereavement trauma detail death cause other text UCLAPTSDRIDSM5BvmtTrDtDthCsOTH The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Bereavement trauma detail death reason' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Bereavement trauma detail death reason' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Cause of Death Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 15:56:31.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 50

Free-Form Entry

C55077 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Injury accidental serious indicator UCLAPTSDRIDSM5InjryAccdlSrsind Indicator of whether the subject/participant has ever been in or seen an accident in which someone could have been hurt or killed, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been in or seen an accident in which someone could have been hurt or killed, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Serious Accidental Injury: Have you ever been in a bad accident (like a serious car, bus, train or bicycle accident or a bad fall) where you or someone else was or could have been badly hurt or killed? Have you ever seen a bad accident where someone was badly hurt or killed? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 09:43:11.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55203 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Behavior risky frequency past month grade UCLAPTSDRIDSM5BhvRskFqPMGrade Grade of frequency during the past month that the subject/participant has engaged in risky behavior, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has engaged in risky behavior, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I do risky or unsafe things that could really hurt me or someone else. 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55117 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - School violence emergency trauma detail type UCLAPTSDRIDSM5SchVcEmTrDtlTyp The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying School Violence/Emergency, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying School Violence/Emergency, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) School Violence/Emergency Trauma Details Shooting;Stabbing;Fire;Suicide;Bomb threat;Assault;Other Shooting;Stabbing;Fire;Suicide;Bomb threat;Assault;Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 14:07:44.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55151 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Suicide attempt trauma detail method type UCLAPTSDRIDSM5ScdAtTrDtlMthTyp The type field for details of method related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Attempted Suicide, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for details of method related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Attempted Suicide, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Method Drug;Hanging;Drowning;Firearm;Other Drug;Hanging;Drowning;Firearm;Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:14:21.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55164 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Affect negative disgust frequency past month grade UCLAPTSDRIDSM5AfNgDgFqPsMGrade Grade of frequency during the past month that the subject/participant has felt disgust about the trauma or loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has felt disgust about the trauma or loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I feel like what happened was sickening or gross 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55088 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Caregiver impaired indicator UCLAPTSDRIDSM5CrgvrImprdInd Indicator of whether the subject/participant has ever been dependent upon someone who was unable to care for him or her, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been dependent upon someone who was unable to care for him or her, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Impaired Caregiver: Was there ever a time when someone who was supposed to take care of you couldn't , like they were too sick, they were so sad they stayed in bed or they had a drinking or drug problem? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 11:04:24.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55228 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause problem home describe text UCLAPTSDRIDSM5SymCsPrbHmDscTxt The free-text field for describing problems at home caused by the subject/participant's PTSD symptoms, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field for describing problems at home caused by the subject/participant's PTSD symptoms, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Describe Alphanumeric

Clinician: Check whether the reactions (thoughts and feelings) above appear to cause clinically significant distress or functional impairment.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 13:30:05.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 255

Free-Form Entry

C55130 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Caregiver impaired trauma detail impairment type UCLAPTSDRIDSM5CrgvImTrDtIptTyp The type field for identifying details of the impairement related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Impaired Caregiver, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details of the impairement related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Impaired Caregiver, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Impairment Due to Medical illness;Mental health problem;Alcohol use/abuse/addiction;Drug use/abuse/addiction Medical illness;Mental health problem;Alcohol use/abuse/addiction;Drug use/abuse/addiction Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 15:02:04.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55191 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Negative assumption self frequency past month grade UCLAPTSDRIDSM5NgAsSfFqPsMGrade Grade of frequency during the past month that the subject/participant has made overly negative assumptions about him or herself, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has made overly negative assumptions about him or herself, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I have thoughts like 'I will never be able to trust other people.' 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55099 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Suicide witness indicator UCLAPTSDRIDSM5SuicdWtnsInd Indicator of whether the subject/participant has ever seen someone after that person attempted or committed suicide, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever seen someone after that person attempted or committed suicide, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Witnessed Suicide: Have you ever seen someone after he/she attempted or committed suicide? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 11:45:21.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55239 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Impairment functional development progression symptom cause indicator UCLAPTSDRIDSM5ImpFncDvPgSCsInd Indicator of whether the subject/participant's PTSD symptoms cause functional impairment in his or her developmental progression, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant's PTSD symptoms cause functional impairment in his or her developmental progression, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Developmental Progression False;True False;True Alphanumeric

check if youth endorses #1 [UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom increase difficulty do important thing peer indicator] below

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 13:33:01.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55141 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Separation trauma detail cause type UCLAPTSDRIDSM5SepTrmDtlCsTyp The type field for identifying causal details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Separation, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying causal details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Separation, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Cause of Separation Parents divorced;Parents separated;Parent deported;Parent hospitalized;Parent/sibling incarcerated;Child placed in foster care;As refugee, separated from relatives/close friends in country of origin;Other Parents divorced;Parents separated;Parent deported;Parent hospitalized;Parent/sibling incarcerated;Child placed in foster care;As refugee, separated from relatives/close friends in country of origin;Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 15:58:50.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55078 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Illness medical trauma indicator UCLAPTSDRIDSM5IllnsMdclTrmaInd Indicator of whether the subject/participant has ever been or seen someone so sick that the subject/participant feared the sick person might die, or has ever had a fearful or painful medical treatment, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been or seen someone so sick that the subject/participant feared the sick person might die, or has ever had a fearful or painful medical treatment, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA P Illness/Medical Trauma: Have you ever been so sick that you and your parents (or people taking care of you) were scared that you might die? Did you have a medical treatment that was very scary or painful? Did you ever see someone you really care about get so sick that you were scared they might die? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 09:48:30.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55204 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Affect negative vengeful frequency past month grade UCLAPTSDRIDSM5AfNgVgFqPMGrade Grade of frequency during the past month that the subject/participant has felt vengeful regarding the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has felt vengeful regarding the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I want to get back at someone for what happened 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55118 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - School emergency violence trauma detail other text UCLAPTSDRIDSM5SchEmVcTrDtlOTH The free-text field related to The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - School emergency violence trauma detail type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) School Violence Emergency Trauma Details Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 14:12:17.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 50

Free-Form Entry

C55152 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Suicide attempt trauma detail method other text UCLAPTSDRIDSM5ScdAtTrDtlMthOTH The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Suicide attempt trauma detail method type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Suicide attempt trauma detail method type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Method Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:19:11.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 30

Free-Form Entry

C55166 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Activity interest decrease frequency past month grade UCLAPTSDRIDSM5AcInDcFqPsMGrade Grade of frequency during the past month that the subject/participant felt decreased interest in activities, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant felt decreased interest in activities, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I don't feel like doing things with my family or friends or other things that I liked to do 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55089 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Rape assault sexual suffer witness indicator UCLAPTSDRIDSM5RpAstSxSfrWtsInd Indicator of whether the subject/participant has ever suffered or witnessed rape or other sexual assault by a non-family, non-resident adult, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever suffered or witnessed rape or other sexual assault by a non-family, non-resident adult, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Sexual Assault/Rape: Did someone outside your family ever force you to do something sexual? Did you ever see someone else being forced to do something sexual? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 11:14:09.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55229 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Impairment functional home symptom cause indicator UCLAPTSDRIDSM5ImpFncHmSyCsInd Indicator of whether the subject/participant's PTSD symptoms cause functional impairment at his or her home, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant's PTSD symptoms cause functional impairment at his or her home, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Home False;True False;True Alphanumeric

check if youth endorses #1 [UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause difficulty get along home indicator], #2 [UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause trouble home indicator], or #3 [UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause other problem home indicator] below

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 13:33:01.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55131 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Caregiver impaired trauma detail relationship type UCLAPTSDRIDSM5CrgvImTrDtRlnTyp The type field for identifying details of the relationship related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Impaired Caregiver, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details of the relationship related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Impaired Caregiver, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Affected Caregiver Mother;Father;Other relative;Other;Other (non-related) adult Mother;Father;Other relative;Other;Other (non-related) adult Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 15:02:04.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55194 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Feel isolated frequency past month grade UCLAPTSDRIDSM5FlIsltFqPsMGrade Grade of frequency during the past month that the subject/participant has felt isolated, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has felt isolated, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I feel alone even when I am around other people 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55100 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type UCLAPTSDRIDSM5TraumaDetailTyp The type of trauma experienced by the subject/participant for which details are being provided, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type of trauma experienced by the subject/participant for which details are being provided, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Trauma Type Serious Accidental Injury;Community Violence;Domestic Violence;War/Political Violence;School Violence/Emergency;Physical Assault;Sexual Assault/Rape;Disaster;Physical abuse;Psychological Maltreatment/Emotional Abuse;Neglect;Sexual abuse;Impaired Caregiver;Kidnapping/Abduction;Terrorism;Bereavement;Separation;Forced Displacement;Trafficking/Sexual Exploitation;Bullying;Attempted Suicide;Witnessed Suicide;Illness/Medical Trauma Serious Accidental Injury;Community Violence;Domestic Violence;War/Political Violence;School Violence/Emergency;Physical Assault;Sexual Assault/Rape;Disaster;Physical abuse;Psychological Maltreatment/Emotional Abuse;Neglect;Sexual abuse;Impaired Caregiver;Kidnapping/Abduction;Terrorism;Bereavement;Separation;Forced Displacement;Trafficking/Sexual Exploitation;Bullying;Attempted Suicide;Witnessed Suicide;Illness/Medical Trauma Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 11:52:09.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55240 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause developmental progression problem other describe text UCLAPTSDRIDSM5SyCsDPPODsTxt The free-text field for describing problems of developmental progression caused by the subject/participant's PTSD symptoms, other than difficulty doing important things that his or her peers are doing, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field for developmental progression problems caused by the subject/participant's PTSD symptoms, other than difficulty doing important things that his or her peers are doing, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Other (describe) Alphanumeric

Clinician: Check whether the reactions (thoughts and feelings) above appear to cause clinically significant distress or functional impairment.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 13:30:05.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 255

Free-Form Entry

C55142 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - War violence political trauma detail type UCLAPTSDRIDSM5WrVlcPolTrDtlTyp The type field for details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying War/Political Violence, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying War/Political Violence, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) War/Political Violence Trauma Details Lived in war-torn region;Saw dead bodies;Saw wounded people;Home damaged/destroyed;Internally displaced;War refugee;Other Lived in war-torn region;Saw dead bodies;Saw wounded people;Home damaged/destroyed;Internally displaced;War refugee;Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 08:22:54.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55079 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Violence community witness fear indicator UCLAPTSDRIDSM5VcCtyWtnsFearInd Indicator of whether the subject/participant has ever witnessed or feared violence in his or her neighborhood, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever witnessed or feared violence in his or her neighborhood, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Community Violence: Did you ever see a bad fight or shooting in your neighborhood, like between gangs? Were you afraid of getting badly hurt or killed? Have you seen someone mugged, robbed, stabbed or killed in your neighborhood? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 10:06:25.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55205 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Depersonalization observer frequency past month grade UCLAPTSDRIDSM5DprObsFqPMGrade Grade of frequency during the past month that the subject/participant has experienced depersonalization as though he or she were an outside observer, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has experienced depersonalization as though he or she were an outside observer, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I feel like I am seeing myself or what I am doing from outside my body (like watching myself in a movie). 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55119 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Assault physical trauma detail type UCLAPTSDRIDSM5AsltPhyTrmDtlTyp The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Physical Assault, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Physical Assault, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Physical Assault Trauma Details Punched;Kicked;Stabbed;Shaken;Weapon Used;Reported to CPS;Reported to police;Other Punched;Kicked;Stabbed;Shaken;Weapon Used;Reported to CPS (if a minor);Reported to police;Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 14:15:09.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55153 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Suicide witness trauma detail type UCLAPTSDRIDSM5ScdWtnTrDtlTyp The type field for details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Attempted Suicide, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Attempted Suicide, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Witnessed Suicide Trauma Details Mother;Father;Brother;Sister;Other relative;Other;Close friend;Acquaintance/schoolmate;Stranger Mother;Father;Brother;Sister;Other relative;Other;Close friend;Acquaintance/schoolmate;Stranger Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:21:06.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55170 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Concentrate difficult frequency past month grade UCLAPTSDRIDSM5CntDfcFqPsMGrade Grade of frequency during the past month that the subject/participant has had difficulty concentrating, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has had difficulty concentrating, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I have trouble concentrating or paying attention 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55090 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Kidnap abduct suffer indicator UCLAPTSDRIDSM5KnpAbdctSfrInd Indicator of whether the subject/participant has ever been kidnapped or abducted, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been kidnapped or abducted, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Kidnapping/Abduction: Have you ever been stolen or kidnapped (taken somewhere against your will) by someone without the permission of your parent or legal guardian? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 11:21:24.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55230 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom increase difficulty do well school indicator UCLAPTSDRIDSM5SyInDfDoWlScInd Indicator of whether the subject/participant's PTSD symptom(s) increase(s) the difficulty he or she has in doing well at school, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant's PTSD symptom(s) increase(s) the difficulty he or she has in doing well at school, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Do these reactions (thoughts and feelings) make it harder for you to do well in school? No;Yes No;Yes Alphanumeric

Clinician: Check whether the reactions (thoughts and feelings) above appear to cause clinically significant distress or functional impairment.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 13:38:45.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55132 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Rape assault sexual trauma detail perpetrator type UCLAPTSDRIDSM5RpAsSxTrDtPrTyp The type field for identifying details about the perpetrator related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Sexual Assault/Rape, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details about the perpetrator related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Sexual Assault/Rape, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Perpetrator Relative;Position of trust;Acquaintance;Stranger Relative;Position of trust (teacher, coach, minister);Acquaintance (neighbor etc);Stranger Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 15:13:35.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55195 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Thought intrusive frequency past month grade UCLAPTSDRIDSM5ThtIntFqPsMGrade Grade of frequency during the past month that the subject/participant has had intrusive thoughts about the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has had intrusive thoughts about the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I have upsetting thoughts, pictures or sounds of what happened come into my mind when I don't want them to. 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55101 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma event role type UCLAPTSDRIDSM5TrmaEvntRolTyp Type specifying the degree of involvement of the subject/participant with the traumatic event type specified in 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type', as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Type specifying the degree of involvement of the subject/participant with the traumatic event type specified in 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type', as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Role in Event Victim;Witness;Learned about Victim;Witness;Learned about Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-20 12:14:04.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55241 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Impairment functional clinically significant indicator UCLAPTSDRIDSM5FnImClnSigInd Indicator of whether the subject/participant's symptoms of PTSD cause clinically significant functional impairment, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant's symptoms of PTSD cause clinically significant functional impairment, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Clinically Significant Functional Impairment False;True False;True Alphanumeric

check if functional impairment at home, at school, in peer relationships, in developmental progression

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96-100. Pediatric Exploratory 1.00 2017-04-21 12:16:54.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

CSV