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
C55137 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Terrorism trauma detail other text UCLAPTSDRIDSM5TerismTrDtlOTH The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Terrorism 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) - Terrorism trauma detail type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Terrorism 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 15:45:17.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 30

Free-Form Entry

C55182 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Avoid thought feel trauma loss try frequency past month grade UCLAPTSDRIDSM5ATFTLTFqPsMGrade Grade of frequency during the past month that the subject/participant has shown avoidance of trauma/loss-related thoughts or feelings, 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 shown avoidance of trauma/loss-related thoughts or feelings, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I try not to think or have feelings about 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

C55095 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Displacement forced suffer indicator UCLAPTSDRIDSM5DsplcmtFrcSfrInd Indicator of whether the subject/participant has ever been forcibly displaced from his or her residence by war, violence, or disaster, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been forcibly displaced from his or her residence by war, violence, or disaster, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Forced Displacement: Have you ever been forced to move out of your house due to war, armed conflict or disaster, like having to move to a trailer or refugee camp? 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 11:35:58.0 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

C55235 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause difficulty make get along friend describe text UCLAPTSDRIDSM5SyCsDfMGAFrDsTxt The free-text field for describing difficulty making or getting along with friends 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 difficulty making or getting along with friends 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

C55148 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Traffic exploit sexual trauma detail type UCLAPTSDRIDSM5TrfExpSxTrDtlTyp The type field for details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Trafficking/Sexual Exploitation, 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 Trafficking/Sexual Exploitation, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Trafficking/Sexual Exploitation Trauma Details Sex for money, food, clothes;Pornography;Sold into prostitution;Sold into slave labor;Other Sex for money, food, clothes;Pornography;Sold into prostitution;Sold into slave labor (unpaid servant or worker);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 08:51:39.0 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

C55200 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Unable recall important part trauma loss frequency past month grade UCLAPTSDRIDSM5URIPTLfFqPMGrade Grade of frequency during the past month that the subject/participant has been unable to recall important parts of 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 been unable to recall important parts of the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I have trouble remembering important parts of 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

C55107 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Illness medical trauma detail type text UCLAPTSDRIDSM5IlMdTrDtlTypTxt The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Illness/Medical Trauma, for describing the type of illness or medical trauma, 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) - Trauma detail type' specifying Illness/Medical Trauma, for describing the type of illness or trauma, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Type 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 12:34:26.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 30

Free-Form Entry

C55247 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Total scale score UCLAPTSDRIDSM5TotalScaleScore Total score for the UCLA PTSD Reaction Index DSM-5, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Total score for the UCLA PTSD Reaction Index DSM-5, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) PTSD-RI Total Scale Score Numeric Values

PTSD-RI Total Scale Score: Sum Category B, C, D, and E

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 15:14:12.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Free-Form Entry

0 40
C55161 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Thought self negative frequency past month grade UCLAPTSDRIDSM5ThSfNgFPMGrade Grade of frequency during the past month that the subject/participant has had overly negative thoughts 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 had self-disparaging thoughts, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I have thoughts like 'I am bad.' 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

C55085 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Abuse physical suffer witness indicator UCLAPTSDRIDSM5AbsPhySfrWtsInd Indicator of whether the subject/participant has ever been subjected to or witnessed severe physical child abuse by a family member or caregiver, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been subjected to or witnessed severe physical child abuse by a family member or caregiver, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Physical Abuse: Have you ever been badly hurt (punched, kicked, stabbed, shaken) by someone who is in your family or was taking care of you? Have you seen another child in your family being badly physically hurt by a parent, caregiver 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 10:46:10.0 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

C55225 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause difficulty get along home indicator UCLAPTSDRIDSM5SmCsDfGtAlHmInd Indicator of whether the subject/participant's PTSD symptom(s) make it difficult for him or her to get along with people 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) make it difficult for him or her to get along with people at home, 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 get along with people 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

C55127 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Neglect trauma detail type UCLAPTSDRIDSM5NglctTrmDtlTyp The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Neglect, 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 Neglect, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Neglect Trauma Details Medical;Left alone/unsupervised;School;Failure to promote health;Failure to promote safety;Other;Reported to CPS;Child removed from home;Caregiver removed from home Medical (did not take to Dr.);Left alone/unsupervised;School;Failure to promote health;Failure to promote safety;Other;Reported to CPS (if a minor);Child removed from home;Caregiver removed from home 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 14:51:26.0 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

C55138 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Bereavement trauma detail relationship type UCLAPTSDRIDSM5BrvmtTrDtlRlnTyp The type field for identifying details about the subject/participant's relationship with the decedent 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 subject/participant's relationship with the decedent 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 Deceased Parent;Sibling;Friend;Other;Other relative Parent;Sibling;Friend;Other;Other relative 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 15:47:21.0 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

C55184 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Reactive physical reminder frequency past month grade UCLAPTSDRIDSM5RaPhRdFqPsMGrade Grade of frequency during the past month that the subject/participant has experienced physical reactivity in response to reminders of 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 experienced physical reactivity in response to reminders of the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) When something reminds me of what happened, I have strong feelings in my body like my heart beats fast, my head aches or my stomach aches. 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

C55096 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Bully suffer peer indicator UCLAPTSDRIDSM5BulySfrPeerInd Indicator of whether the subject/participant has ever been bullied by a peer, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been bullied by a peer, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Bullying: Has someone your age or a student at your school ever bullied you, like kept calling you dirty names, making sexual comments, threatening to beat you up or spreading mean rumors around school or online? 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 11:38:12.0 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

C55236 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Impairment functional peer relationship symptom cause indicator UCLAPTSDRIDSM5ImpFncPRSyCsInd Indicator of whether the subject/participant's PTSD symptoms cause functional impairment in his or her peer relationships, 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 peer relationships, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Peer Relationships False;True False;True Alphanumeric

check if youth endorses #1 [UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom increase difficulty make get along friend 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

C55149 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Bully trauma detail type UCLAPTSDRIDSM5BullyTrDtlTyp The type field for details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Bullying, 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 Bullying, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Bullying Trauma Details Verbal insults;Threats of physical harm;Sexual comments;Rumors at school/internet;Other Verbal insults;Threats of physical harm;Sexual comments;Rumors at school/internet;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 08:56:54.0 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

C55201 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Startle reaction heighten frequency past month grade UCLAPTSDRIDSM5StRcHifFqPMGrade Grade of frequency during the past month that the subject/participant has had a heightened startle reaction, 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 a heightened startle reaction, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I feel jumpy or startle easily, like when I hear a loud noise or when something surprises me. 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

C55112 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Violence community trauma detail type UCLAPTSDRIDSM5VlcCmtyTrmDtlTyp The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Community 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 Community Violence, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Community Violence Trauma Details Robbery;Mugging;Killed;Gang-Related;High Crime Community;Drug Traffic;Other Robbery;Mugging;Killed;Gang-Related;High Crime Community;Drug Traffic;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 13:53:49.0 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

C55248 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - DSM-5 PTSD diagnosis status UCLAPTSDRIDSM5DSM5PTSDDgnsStat Status(es) of DSM-5 PTSD diagnosis, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Status(es) of DSM-5 PTSD diagnosis, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) DSM-5 PTSD Diagnosis B;C;D;E;F;G;One or more dissociative symptoms present One or more Category B symptoms present;One or more Category C symptoms present;Two or more Category D symptoms present;Two or more Category E symptoms present;Symptom duration greater than one month;Symptoms cause clinically significant distress or impairment;One or more dissociative symptoms present Alphanumeric

If symptom score is 3 or 4, then score symptom as "present." For question #4, #10, and #26; use a rating of 2 or more for symptom presence. Then determine whether one or more B symptoms are present; whether one or more C symptoms are present; whether two or more D symptoms are present; and whether two or more E symptoms are present. If one or more Dissociative Symptoms are present, then assign Dissociative Subtype.

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 15:17:35.0 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

C55162 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Reminder physical avoid frequency past month grade UCLAPTSDRIDSM5RdPhAvFqPsMGrade Grade of frequency during the past month that the subject/participant has avoided physical reminders 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 avoided physical reminders of the trauma or loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I try to stay away from people, places, or things that remind me about 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

C55086 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Neglect suffer indicator UCLAPTSDRIDSM5NeglctSuffrInd Indicator of whether the subject/participant has ever been neglected by an unimpaired caregiver or other adult responsible 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 neglected by an unimpaired caregiver or other adult responsible for him or her, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Neglect: Has there ever been a time when someone who should have been taking care of you didn't , like they didn't take you to a doctor when you were really sick, they left you alone for too long, didn't make sure you were going to school or didn't do their best to keep you healthy or safe? 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 10:50:21.0 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

C55226 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause trouble home indicator UCLAPTSDRIDSM5SmCsTrblHmInd Indicator of whether the subject/participant's PTSD symptom(s) cause him or her to get in trouble 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 him or her to get in trouble at home, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Do these reactions (thoughts and feelings) get you into trouble 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

C55128 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Abuse psychological emotional trauma detail type UCLAPTSDRIDSM5AbsPsyEmTrDtTyp The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Psychological Maltreatment/Emotional Abuse, 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 Psychological Maltreatment/Emotional Abuse, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Psychological Maltreatment/Emotional Abuse Trauma Details Berating/humiliating;Threatened abandonment;Excessive punishment;Other Berating/humiliating;Threatened abandonment;Excessive punishment;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 14:56:23.0 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

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

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

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

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

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

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

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

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

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

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

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

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

CSV