CDE Detailed Report

Disease: Sport Related Concussion
Subdomain Name: History of Disease%2FInjury Event
CRF: Injury Report

Displaying 51 - 82 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
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%2FInjury Event Disease%2FInjury 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%2FInjury Event Disease%2FInjury Related Events 4000

Free-Form Entry
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%2FInjury Event Disease%2FInjury 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%2FInjury Event Disease%2FInjury 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%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value 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%2FInjury Event Disease%2FInjury Related Events

Multiple Pre-Defined Values 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%2FInjury Event Disease%2FInjury 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%2FInjury Event Disease%2FInjury Related Events

Multiple Pre-Defined Values Selected
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%2FInjury Event Disease%2FInjury Related Events 255

Free-Form Entry
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%2FInjury Event Disease%2FInjury Related Events 4000

Free-Form Entry
C55470 Concussion assessment baseline exist indicator CncssnAssmntBslnExstInd Indicator of whether a baseline evaluation exists for the subject/participant to aid in concussion assessment Indicator of whether a baseline evaluation exists for the subject/participant to aid in concussion assessment Does subject have a baseline? No;Yes No;Yes Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 13:33:51.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C55539 Injury orthopedic non concussive anatomic site InjOrthpdcNoCncsvAnatSite Anatomic site(s) of non-concussive orthopedic suspected injuries incurred by the subject/participant Anatomic site(s) of non-concussive orthopedic suspected injuries incurred by the subject/participant Did/Does athlete have any other orthopedic injuries? Neck;Shoulder;Arm/Elbow;Wrist/Hand/Fingers;Back;Trunk;Knee;Hip/Thigh;Lower leg/Foot/Toe;Head (non-concussive) Neck;Shoulder;Arm/Elbow;Wrist/Hand/Fingers;Back;Trunk;Knee;Hip/Thigh;Lower leg/Foot/Toe;Head (non-concussive) Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 13:25:20.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Multiple Pre-Defined Values Selected
C01053 Loss of consciousness duration range LOCDurRang The range of duration of loss of consciousness the participant/subject experienced The range of duration of loss of consciousness the participant/subject experienced Loss of consciousness duration <1 minute;1-29 minutes;30 minutes to 24 hours <1 minute;1-29 minutes;30 minutes to 24 hours Alphanumeric Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C12245 Symptom presentation type SymptmPresentTyp Symptoms participant/ subject shows at presentation Symptoms participant/ subject shows at presentation Symptoms Balance problems;Dizziness;Fogginess/confusion;Headache;Memory loss;Nausea/vomiting;Vision Changes Balance problems;Dizziness;Fogginess/confusion;Headache;Memory loss;Nausea/vomiting;Vision Changes Alphanumeric Adult;Pediatric Supplemental 3.10 2017-05-12 12:45:20.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Multiple Pre-Defined Values Selected
C55484 Injury immediate medical service received other text InjImmdtMedServRecvdOTH The free-text field related to 'Injury immediate medical service received type' specifying other text The free-text field related to 'Injury immediate medical service received type' specifying other text Medical Services received: Other, specify Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 16:50:20.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events 255

Free-Form Entry
C55567 Academic year current organize sport grade AcadYrCurrOrganizSportGrade Grade representing the current year of schooling for which the subject/participant is participating in organized sport Grade representing the current year of schooling for which the subject/participant is participating in organized sport Current academic year in which your child will be participating in enrolled sport (i.e. basline test in spring or summer for fb, academic year is what they will be when participating in sport in fall) 6th Grade;7th Grade;8th Grade;College-5th Yr;College-6th Yr;College-Fr;College-Jr;College-So;College-Sr;HS-Fr;HS-Jr;HS-So;HS-Sr 6th Grade;7th Grade;8th Grade;Fifth year of college;Sixth year of college;College freshman;College junior;College sophomore;College senior;High school freshman;High school junior;High school sophomore;High school senior Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 15:57:01.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C54336 Acute Concussion Evaluation (ACE) - Impact location anatomic site ACEImpactLocationAnatSite Anatomic site of impact injury as related to the Acute Concussion Evaluation (ACE) Anatomic site of impact injury as related to the Acute Concussion Evaluation (ACE Location of impact Frontal;Indirect Force;Left Parietal;Left Temporal;Neck;Occipital;Right Parietal;Right Temporal Frontal;Indirect Force;Left Parietal;Left Temporal;Neck;Occipital;Right Parietal;Right Temporal Alphanumeric Adult;Pediatric Supplemental 1.00 2017-02-27 20:16:54.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Multiple Pre-Defined Values Selected
C55507 Dizziness vertigo duration range DizznsVrtgoDuratnRng Range of time within which the duration of the subject/participant's dizziness or vertigo falls Range of time within which the duration of the subject/participant's dizziness or vertigo fall Dizziness duration Less than 1 hour;1-24 hours;>24 hours Less than 1 hour;1-24 hours;>24 hours Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 12:10:01.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C55472 Remove participation activity indicator RmvPrtcptnActvtyInd Indicator of whether subject/participant was removed from participation in the activity in which he or she incurred the condition or injury being documented Indicator of whether subject/participant was removed from participation in the activity in which he or she incurred the condition or injury being documented Was athlete taken out of game? No;Yes No;Yes Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 13:54:14.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C55540 Neck sore uninjured indicator NeckSoreUninjurdInd Indicator of whether the subject/participant's neck is sore but otherwise uninjured Indicator of whether the subject/participant's neck is sore but otherwise uninjured Neck sore but not injured No;Yes No;Yes Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 13:31:57.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C01055 Post traumatic amnesia duration range PstTraumAmnsDurRang The range of duration of post-traumatic amnesia the participant/subject experienced The range of duration of post-traumatic amnesia the participant/subject experienced Post traumatic amnesia duration >24 hours;<1 hour;1-24 hours >24 hours;<1 hour;1-24 hours Alphanumeric Adult;Pediatric Supplemental 3.10 2017-05-12 12:30:51.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C13523 Dizziness or vertigo indicator DizzinessVertigoInd Indicator of whether the participant/subject experienced dizziness or vertigo Indicator of whether the participant/subject experienced dizziness or vertig Dizziness Yes;No Yes;No Alphanumeric Adult;Pediatric Supplemental 3.00 2013-06-21 00:00:00.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C55485 Injury activity circumstance type InjActvtyCrcmstncTyp Type of circumstances of the activity during which the suspected injury was incurred Type of circumstances of the activity during which the suspected injury was incurred Injury occurred during Training;Other;Game;Practice;Dryland/fitness Training;Other;Game;Practice;Dryland/fitness Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 16:53:27.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C55569 Educational assistance supplemental formal indicator EduAsstncSupplFormlInd Indicator of whether the subject/participant has ever received formal supplemental educational assistance, such as an Individualized Education Program (IEP) Indicator of whether the subject/participant has ever received formal supplemental educational assistance, such as an Individualized Education Program (IEP) Have you ever had an IEP (Individualized Education Program) or extra support for studies? Yes;No;Unknown Yes;No;Unknown Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 16:08:25.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C54338 Acute Concussion Evaluation (ACE) - Injury cause type sports text ACEInjuryCauseTypSportsTxt Text specifying the cause of the impact injury as related to the Acute Concussion Evaluation (ACE) Text specifying the cause of the impact injury as related to the Acute Concussion Evaluation (ACE Sport at time of injury Alphanumeric Adult;Pediatric Supplemental 1.00 2017-02-27 20:29:51.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events 255

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C55508 Amnesia retrograde duration range AmnsiaRtrogrdDuratnRng Range of time within which the duration of the subject/participant's retrograde amnesia falls Range of time within which the duration of the subject/participant's retrograde amnesia falls Retrograde amnesia duration Less than 1 hour;1-24 hours;>24 hours Less than 1 hour;1-24 hours;>24 hours Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 12:17:20.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C55473 Injury report delay elapsed time duration InjRptDlyElpsdTimDur Duration of time elapsed between occurrence of injury and initial report of injury by subject/participant if not immediately reported Duration of time elapsed between occurrence of injury and initial report of injury by subject/participant if not immediately reported How many minutes/hours after injury did athlete report it to someone? Numeric Values Adult;Pediatric Supplemental 1.00 2017-05-11 14:50:06.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Free-Form Entry

 0
C55541 Concussion prior current year text ConcusnPriorCurrYrTxt The free-text field for documenting prior concussions suffered by the subject/participant during the current year The free-text field for documenting prior concussions suffered by the subject/participant during the current year Repeat concussion this year Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 13:35:06.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events 4000

Free-Form Entry
C04813 Return work school status RtrnWrkSchlStatus Status of participant's/subject's return to work and/or school Status of participant's/subject's return to work and/or school Return to work/school Returned to previous level;Same work or school, reduced level;Different work or school;Only in sheltered environment;Did not return to work or school;N/A;Unknown Returned to previous level;Same work or school, reduced level;Different work or school;Only in sheltered environment;Did not return to work or school;N/A;Unknown Alphanumeric Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C17499 Special education indicator SpecialEduInd Indicator as to whether the participant/subject has or had special education Indicator as to whether the participant/subject has or had special education Does your child have a history of Special Education? For example, have you had any special classes or accommodations in school? Yes;No;Unknown Yes;No;Unknown Alphanumeric Adult;Pediatric Supplemental 3.00 2013-07-15 16:08:48.687 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Single Pre-Defined Value Selected
C55486 Equipment protective worn injury incur type EqpmntPrtctvWrnInjryIncrTyp Type of protective equipment being worn by the subject/participant when he or she incurred the suspected injury Type of protective equipment being worn by the subject/participant when he or she incurred the suspected injury At the time of injury, was any protective equipment worn? Helmet;Mouthguard;Brace;Tape;Other Helmet;Mouthguard;Brace;Tape;Other Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-11 16:57:20.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Multiple Pre-Defined Values Selected
C55570 Educational assistance supplemental formal subject type EduAsstncSupplFormlSbjTyp Type of academic subject(s) for which the subjec/participant received formal supplemental educational assistance, such as an Individualized Education Program (IEP) Type of academic subject(s) for which the subjec/participant received formal supplemental educational assistance, such as an Individualized Education Program (IEP) What did you have an IEP in? Reading;Writing;Math;Other Reading;Writing;Math;Other Alphanumeric Adult;Pediatric Supplemental 1.00 2017-05-12 16:11:30.0 Injury Report History of Disease%2FInjury Event Disease%2FInjury Related Events

Multiple Pre-Defined Values Selected
CSV