CDE Detailed Report

Disease: content
Subdomain Name: History of Disease/Injury Event
CRF: welcome

Displaying 1 - 50 of 82
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
C55475 Injury report immediate indicator InjRptImmedInd Indicator of whether the injury was reported by the injured party immediately upon occurrence Indicator of whether the injury was reported by the injured party immediately upon occurrence Did athlete immediately report the injury? No;Yes No;Yes Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 16:05:32.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55543 Days school missed count range DaysSchoolMissedCtRng Range in which the count of days of school missed by the subject/participant falls Range in which the count of days of school missed by the subject/participant falls Approximately how many days of school has the child missed? 1-2 days;0 days;3–6 days;7 or more days 1-2 days;0 days;3–6 days;7 or more days Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 13:48:24.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C05404 Symptom onset date and time SymptmOnsetDateTime Date (and time, if applicable and known) reported for onset of participant's/subject's symptoms Date (and time, if applicable and known) reported for onset of participant's/subject's symptoms Symptom onset date; Symptom onset time Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

 Adult;Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry
C55496 Injury onset participant involvment category InjOnstPtcptInvlvmntCat Category of onset speed of the suspected injury and involvment of other participants in the activity in which the subject/participant incurred the suspected injury Category of onset speed of the suspected injury and involvment of other participants in the activity in which the subject/participant incurred the suspected injury Injury involved: Gradual onset/overuse;Sudden onset and contact with another participant;Sudden onset and no contact with another participant;Unknown Gradual onset/overuse;Sudden onset and contact with another participant;Sudden onset and no contact with another participant;Unknown Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 10:36:03.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55573 Pain intensity visual analogue scale value PainIntnstyVslAnalogSclVal Value indicated by the subject/participant for his or her pain intensity using a visual analogue scale Value indicated by the subject/participant for his or her pain intensity using a visual analogue scale Pain assessment Numeric Values Adult;Pediatric Supplemental 1.00 2017-05-12 16:23:04.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

 0 10
C19197 Injury time InjuryTime Time of injury Time of injury Time of Injury (24 hour clock) Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

 Adult;Pediatric Supplemental 1.00 2014-06-02 16:13:18.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry
C55517 Symptom duration value SymptmDuratnVal Value for the duration of the symptom(s) being documented Value for the duration of the symptom(s) being documented How long did symptoms last after injury/impact? Numeric Values Adult;Pediatric Supplemental 1.00 2017-05-12 12:33:35.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

 0
C55463 Injury data reliability category InjDataReliablCat Category of reliability for the injury data being reported Category of reliability for the injury data being reported Reliability of injury data Verified;Estimated;Unknown Verified;Estimated;Unknown Alphanumeric Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55477 Participation continue activity post injury indicator PtcptnCntnuActvtyPostInjyInd Indicator of whether the injured party continued to participate in the activity in which he or she received the suspected injury, after the occurrence of the suspected injury Indicator of whether the injured party continued to participate in the activity in which he or she received the suspected injury, after the occurrence of the suspected injur Did athlete continue participation after suspected injury event? No;Yes No;Yes Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 16:08:03.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55558 Education current level USA type EduCurrLvlUSATyp Current grade or level of school in which participant/subject is enrolled Current grade or level of school in which participant/subject is enrolled Please indicate the grade that your child is currently enrolled in: 1st Grade;2nd Grade;3rd Grade;4th Grade;5th Grade;6th Grade;7th Grade;8th Grade;9th Grade;10th Grade;11th Grade;12th Grade;Kindergarten;Not currently enrolled;Other, specify 1st Grade;2nd Grade;3rd Grade;4th Grade;5th Grade;6th Grade;7th Grade;8th Grade;9th Grade;10th Grade;11th Grade;12th Grade;Kindergarten;Not currently enrolled;Other, specify Alphanumeric Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected

 3134878
C05406 Hospital first treat arrival date time HospFirstTreatArrDateTime Date (and time, if applicable and known) of arrival at the first hospital, if the participant/subject was transferred to the study center from another hospital Date (and time, if applicable and known) of arrival at the first hospital, if the participant/subject was transferred to the study center from another hospital Date treated at hospital; Time treated at hospital Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

 Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry
C55497 Injury cause activity behavior text InjCausActvtyBehvrTxt The free-text field for describing the activity behavior or action that caused the suspected injury The free-text field for describing the activity behavior or action that caused the suspected injury Cause of injury (will depend on sport) – body check, tackle, intentional player contact (elbowing, roughing, cross-check, dueling for header, etc) Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 10:42:48.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events 255

Free-Form Entry
C22622 Wong-Baker FACES - Pain rating scale WongBakerFacesPainRatingScale This scale uses faces and corresponding numbers to indicate the amount of pain the subject feels This scale uses faces and corresponding numbers to indicate the amount of pain the subject feel Pain assessment 0;10;2;4;6;8 No Hurt;Hurts Worst;Hurts Little Bit;Hurts Little More;Hurts Even More;Hurts Whole Lot Numeric Values Pediatric Supplemental 1.00 2016-07-13 13:21:18.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55518 Symptom duration unit of measure SymptmDuratnUOM Unit of measure related to 'Symptom duration value' Unit of measure related to 'Symptom duration value' How long did symptoms last after injury/impact? Days;Hours;minutes Days;Hours;minutes Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 12:35:09.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55464 Assessment clinical perform occupation type AssmntClnclPrfrmOccptnTyp Type of occupation of the person performing the clinical assessment Type of occupation of the person performing the clinical assessment Who was the clinical assessment completed by? Medical doctor;Athletic trainer;Coach;Physician's Assistant;Physical therapist;Other Medical doctor;Athletic trainer;Coach;Physician's Assistant;Physical therapist;Other Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 12:34:42.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55479 Participation continue activity post injury duration text PrtcptnCntnActvPstInjDurtnTxt Text specifying the duration for which the subject/participant continued to participate in the activity in which he or she incurred the suspected injury, after incurring the suspected injury Text specifying the duration for which the subject/participant continued to participate in the activity in which he or she incurred the suspected injury, after incurring the suspected injur If so, for how long? Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 16:14:45.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events 50

Free-Form Entry
C55559 Education current level USA text EduCurrLvlUSAOTH The free-text field related to 'Education current level USA type' specifying other text The free-text field related to 'Education current level USA type' specifying other text Please indicate the grade that your child is currently enrolled in: other, specify: Alphanumeric Pediatric Supplemental 1.00 2017-05-12 15:31:40.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events 255

Free-Form Entry
C05408 Hospital admission date and time HospitlAdmissDateTime Date (and time, if applicable and known) the participant/subject was admitted to the hospital Date (and time, if applicable and known) the participant/subject was admitted to the hospital Hospital admission date; Hospital admission time Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

 Adult;Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry
C55498 Participant activity penalize indicator PtcpntActvtyPnlzInd Indicator of whether a participant in the activity in which the subject/participant incurred the suspected injury was penalized for conduct directly related to the injury event Indicator of whether a participant in the activity in which the subject/participant incurred the suspected injury was penalized for conduct directly related to the injury event Was a penalty called directly related to the injury event No;Yes No;Yes Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 11:37:05.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C22804 Pain present eleven point intensity scale PainPrsnt11IntensityScl Scale for the participant's current pain intensity based on an a scale of 0-10 Scale for the participant's current pain intensity based on an a scale of 0-10 Pain assessment 0;1;10;2;3;4;5;6;7;8;9 0;1;10;2;3;4;5;6;7;8;9 Numeric Values Adult;Pediatric Supplemental 4.00 2023-05-18 16:39:30.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55465 Concussion determine confidence category CncssnDtrmnCnfdncCat Category of the clinical assessor's confidence in his or her determination that the injury was a concussion Category of the clinical assessor's confidence in his or her determination that the injury was a concussion How confident was clinician that injury was a concussion? Barely confident;Fairly confident;Not at all confident;Somewhat confident;Very confident Barely confident;Fairly confident;Not at all confident;Somewhat confident;Very confident Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 13:12:30.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55527 Headache Impact Test 6 baseline score HIT6BaselineScore Score obtained from a baseline administration of the Headache Impact Test-6 (HIT-6) Score obtained from a baseline administration of the Headache Impact Test-6 (HIT-6) Baseline Headache Impact Test-6 (HIT-6) Numeric Values Adult;Pediatric Supplemental 1.00 2017-05-12 12:58:31.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

 36 78
C55480 Participation continue activity post injury turn count PrtcptnCntnuActvyPostInjTurnCt Count of discrete turns for which the subject/participant continued to participate in the activity in which the suspected injury was received, after receiving the suspected injury Count of discrete turns for which the subject/participant continued to participate in the activity in which the suspected injury was received, after receiving the suspected injury For how many plays? Numeric Values Adult;Pediatric Supplemental 1.00 2017-05-11 16:17:55.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

 0 Turns
C55561 Academic achievement average USA category AcdmcAchvmntAvgUSACat Category describing the average academic achievement of the subject/participant in relation to the typical academic achievement scale used in the USA Category describing the average academic achievement of the subject/participant in relation to the typical academic achievement scale used in the USA Please indicate your child's average academic achievement prior to the concussion A & B grades;B & C grades;Below C grades;Straight A student;Straight B student A & B grades;B & C grades;Below C grades;Straight A student;Straight B student Alphanumeric Pediatric Supplemental 1.00 2017-05-12 15:34:02.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C05411 Injury immediate medical service receive indicator InjImmdtMedclServRecvdInd Indicator of whether initial medical services were received directly after injury Indicator of whether initial medical services were received directly after injury Were initial medical services received immediately after injury? Yes;No;Unknown Yes;No;Unknown Alphanumeric Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55499 Participant activity penalize text PtcpntActvtyPnlzTxt Free-text field for describing any penalty for conduct directly related to the injury event that was assessed to a participant in the activity in which the subject/participant incurred the suspected injury Free-text field for describing any penalty for conduct directly related to the injury event that was assessed to a participant in the activity in which the subject/participant incurred the suspected injury Was a penalty called directly related to the injury event: if yes, describe Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 11:37:05.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events 255

Free-Form Entry
C52398 Injury mechanism type InjuryMechTyp The type of mechanism leading to the subject's injury The type of mechanism leading to the subject's injury Mechanism of injury Direct blow to head;Fell and hit head;Hit head on environment;Non-head injury;Contact with another participant;Impact with ground;Impact with object Direct blow to head;Fell and hit head;Hit head on environment;Non-head injury;Contact with another participant;Impact with ground;Impact with object (i.e., ball) Alphanumeric Adult;Pediatric Supplemental 1.10 2017-05-12 11:35:57.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected
C55467 First evaluation injury elapsed hour count FrstEvalInjElpsdHrCt Count of hours elapsed between the injury and the first evaluation Count of hours elapsed between the injury and the first evaluation How many hours after the injury did the first evaluation take place? Numeric Values Adult;Pediatric Supplemental 1.00 2017-05-11 13:27:39.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

 0 Hours
C55528 Headache Impact Test 6 follow-up score HIT6FollowupScore Score obtained from a follow-up administration of the Headache Impact Test-6 (HIT-6) Score obtained from a follow-up administration of the Headache Impact Test-6 (HIT-6) Follow-up Headache Impact Test-6 (HIT-6) Numeric Values Adult;Pediatric Supplemental 1.00 2017-05-12 12:58:31.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

 36 78
C55481 Emergency room visit indicator ERVisitInd Indicator of whether the subject/participant visited an emergency room (ER) or equivalent facility Indicator of whether the subject/participant visited an emergency room (ER) or equivalent facilit Did athlete go to ER? No;Yes No;Yes Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 16:26:22.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55562 Imaging prior head injury CT MRI indicator ImgPriorHdInjCTMRIInd Indicator of whether the subject/participant was given a CT or MRI scan for a previous head injury Indicator of whether the subject/participant was given a CT or MRI scan for a previous head injury Has your child had a CT or MRI for a PREVIOUS head injury? Yes;No;Unknown Yes;No;Unknown Alphanumeric Pediatric Supplemental 1.00 2017-05-12 15:42:56.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C05412 Injury immediate medical service received type InjImmdtMedServRecvdTyp Type of initial medical services received directly after injury Type of initial medical services received directly after injury Medical Services received CT/MRI;Hospitalization;Specialized therapies (speech, physical, occupational therapy);Evaluations (neurological, psychological);Medication;Education about course of symptoms;Other, specify CT/MRI;Hospitalization;Specialized therapies (speech, physical, occupational therapy);Evaluations (neurological, psychological);Medication;Education about course of symptoms;Other, specify Alphanumeric Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected
C55500 Participant activity penalize identify text PtcpntActvtyPnlzIdntfyTxt Free-text field for identifying the participant(s) in the activity in which the subject/participant incurred the suspected injury who was/were assessed a penalty for conduct directly related to the injury event Free-text field for identifying the participant(s) in the activity in which the subject/participant incurred the suspected injury who was/were assessed a penalty for conduct directly related to the injury event Who received penalty Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 11:37:05.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events 255

Free-Form Entry
C52400 Injury date InjuryDate The date the subject received his or her injury The date the subject received his or her injury Date Injury Occurred Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

 Adult;Pediatric Supplemental 1.00 2017-01-18 09:25:29.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry
C55468 Second evaluation injury elapsed hour count ScndEvalInjElpsdHrCt Count of hours elapsed between the injury and the second evaluation Count of hours elapsed between the injury and the second evaluation How many hours after the injury did the second evaluation take place? Numeric Values Adult;Pediatric Supplemental 1.00 2017-05-11 13:27:39.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

 0 Hours
C55534 Suicide ideation text SuicideIdeationTxt The free-text field for describing suicidal ideation The free-text field for describing suicidal ideation Suicidal ideation Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 13:17:21.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events 4000

Free-Form Entry
C01037 Post traumatic amnesia indicator PstTraumtcAmnsInd The indicator for whether the participant/subject experienced any period of post-traumatic amnesia. The indicator for whether the participant/subject experienced any period of post-traumatic amnesia. Post traumatic amnesia Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55482 Injury treatment hospital prior study center indicator InjTxHospPriorStyCtrInd Indicator of whether the subject/participant received treatement for his or her suspected injury at a hospital prior to being seen at the study center Indicator of whether the subject/participant received treatement for his or her suspected injury at a hospital prior to being seen at the study cente Treated at hospital before study center? No;Yes No;Yes Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 16:30:54.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55563 Hospitalize prior head injury indicator HosptlzePriorHdInjInd Indicator of whether the subject/participant has ever been hospitalized for a previous head injury Indicator of whether the subject/participant has ever been hospitalized for a previous head injury Has your child been hospitalized for a previous head injury? Yes;No;Unknown Yes;No;Unknown Alphanumeric Pediatric Supplemental 1.00 2017-05-12 15:45:58.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C05460 Seizure indicator SeizInd Indicator of seizure activity Indicator of seizure activity After your child's head injury did he/she have a seizure? Yes;No Yes;No Alphanumeric Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55501 Injury type location anatomic site InjTypLocAnatSite The free-text field for specifying the types and locations of suspected injuries The free-text field for specifying the types and locations of suspected injuries Injury location for each type of injury (often more than one injury at time of injury- list of all injury types and body parts) Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 11:48:53.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events 4000

Free-Form Entry
C52426 Sport Concussion Assessment Tool - 3rd Edition (SCAT3) - Disorientation confusion indicator SCAT3DisorientConfusInd The indicator relating to whether or not the subject has any disorientation or confusion, as part of the Sport Concussion Assessment Tool - 3rd Edition (SCAT3) The indicator relating to whether or not the subject has any disorientation or confusion, as part of the Sport Concussion Assessment Tool - 3rd Edition (SCAT3 Confusion/disorientation Y;N Yes;No Alphanumeric Adult;Pediatric Supplemental 1.00 2017-01-18 14:14:31.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55469 Third evaluation injury elapsed hour count ThrdEvalInjElpsdHrCt Count of hours elapsed between the injury and the third evaluation Count of hours elapsed between the injury and the third evaluation How many hours after the injury did the third evaluation take place? Numeric Values Adult;Pediatric Supplemental 1.00 2017-05-11 13:27:39.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Free-Form Entry

 0 Hours
C55535 Injury orthopedic non concussive indicator InjuryOrthopedicNoConcusInd Indicator of whether the subject/participant has any non-concussive orthopedic injuries Indicator of whether the subject/participant has any non-concussive orthopedic injuries Did/Does athlete have any other orthopedic injuries? No;Yes No;Yes Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 13:19:17.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected
C01052 Loss of consciousness indicator LOCInd The indicator for whether the participant/subject experienced any period of loss of consciousness (LOC) The indicator for whether the participant/subject experienced any period of loss of consciousness (LOC Loss of consciousness Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55483 Hospital admission date time not applicable status HospAdmsnDtTmNoAplcblStatus Status indicating that date and time of hospital admission does not apply to the subject/participant Status indicating that date and time of hospital admission does not apply to the subject/participant Hospital admission date N/A N/A Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 16:38:31.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Single Pre-Defined Value Selected
C55565 Medication post injury type MedicatnPostInjTyp Type(s) of medication(s) received by the subject/participant after incurring the suspected injury Type(s) of medication(s) received by the subject/participant after incurring the suspected injury Specify which medication(s) your child received since the time of their injury Gravol;Acetaminophen;Ibuprofen;Other, specify Gravol;Acetaminophen (Tylenol, Tempra);Ibuprofen (Advil, Motrin);Other, specify Alphanumeric Pediatric Supplemental 1.00 2017-05-12 15:50:47.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected
C08147 Data source DataSource Source of the data provided on the case report form Source of the data provided on the case report form Source of information Clinician;Coach;Other;Parent;Player Clinician;Coach;Other;Parent;Player Alphanumeric Adult;Pediatric Supplemental 3.00 2013-07-20 10:46:24.96 Injury Report History of Disease/Injury Event Disease/Injury Related Events

Multiple Pre-Defined Values Selected
C55504 Injury circumstance describe text InjCrcmstncDscrbTxt The free-text field for describing the circumstances of the occurrence of the suspected injury The free-text field for describing the circumstances of the occurrence of the suspected injury Describe events surrounding the injury Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 11:59:39.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events 4000

Free-Form Entry
C54333 Acute Concussion Evaluation (ACE) ? Injury description text ACEInjuryDescriptnTxt Text of injury description as related to the Acute Concussion Evaluation (ACE) Text of injury description as related to the Acute Concussion Evaluation (ACE) Injury description Alphanumeric Adult;Pediatric Supplemental 1.00 2017-02-27 19:20:57.0 Injury Report History of Disease/Injury Event Disease/Injury Related Events 255

Free-Form Entry
CSV