|
subjectkey |
GUID |
|
Required |
The NDAR Global Unique Identifier (GUID) for research subject |
NDAR*
|
|
|
|
src_subject_id |
String |
20
|
Required |
Subject ID how it's defined in lab/project |
|
|
CATIEID, bid |
|
interview_date |
Date |
|
Required |
Date on which the interview/genetic test/sampling/imaging/biospecimen was completed. MM/DD/YYYY |
|
|
|
|
interview_age |
Integer |
|
Required |
Age in months at the time of the interview/test/sampling/imaging. |
0 :: 1260
|
Age is rounded to chronological month. If the research participant is 15-days-old at time of interview, the appropriate value would be 0 months. If the participant is 16-days-old, the value would be 1 month.
|
dema1 |
|
sex |
String |
20
|
Required |
Sex of subject at birth |
M;F; O; NR
|
M = Male; F = Female; O=Other; NR = Not reported
|
dema2, gender |
Query
|
visitid |
Integer |
|
Recommended |
MetaTrial Visit ID |
|
System variable: unique code for each type of visit -use to merge files
|
|
Query
|
visit |
String |
60
|
Recommended |
Visit name |
|
|
|
Query
|
truncvis |
Integer |
|
Recommended |
Truncated Visit Number |
|
Created variable: provides a numeric visit number for all visits, including unscheduled and end of phase
|
|
Query
|
phase_ct |
String |
20
|
Recommended |
Current Phase. Phase patient was in at the time of the assessment Phase 4 refers to the follow-up phase. |
Pre-Rand; Phase 1/1A; Phase 2; Phase 3; Phase 4; Phase 1B; Open-Choice Phase; Screening; Phase 1
|
|
|
Query
|
visday |
Integer |
|
Recommended |
Number of days from study baseline to date of visit |
|
|
|
|
protocol |
String |
50
|
Recommended |
Protocol [Study] name |
|
|
|
Query
|
surfm1 |
Integer |
|
Recommended |
1. Is todays visit intended as a psychoeducational session? |
0;1
|
0=No; 1=Yes
|
|
Query
|
surfm1a |
Integer |
|
Recommended |
1a. If yes, is the session for |
1;2
|
1 = Patient only; 2 = Patient and family
|
|
Query
|
inpat1 |
Integer |
|
Recommended |
2. Were you hospitalized for at least one night for any of the following reasons during the last month? |
0;1
|
0=No; 1=Yes
|
|
Query
|
inpat1a |
Integer |
|
Recommended |
2a. If yes, check all that apply: Inpatient care |
0;1
|
0=No; 1=Yes
|
|
Query
|
inpat1b |
Integer |
|
Recommended |
b. If yes, check all that apply: Surgical problem |
0;1
|
0=No; 1=Yes
|
surfm01b |
Query
|
inpat1c |
Integer |
|
Recommended |
c. If yes, check all that apply: Psychiatric problem |
0;1
|
0=No; 1=Yes
|
surfm01c |
Query
|
inpat1d |
Integer |
|
Recommended |
d. If yes, check all that apply: Substance abuse problem |
0;1
|
0=No; 1=Yes
|
surfm01d |
Query
|
servcode |
Integer |
|
Recommended |
Service code (reason for admission) |
1::5
|
1 = Medical - e.g., neurological; 2 = Surgical; 3 = Psychiatric - non-substance abuse; 4 = Drug Abuse - not alcohol; 5 = Alcohol Abuse
|
|
Query
|
hosptype |
Integer |
|
Recommended |
3b. Hospital Type |
1::6
|
1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; 4 = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility
|
|
Query
|
night |
Integer |
|
Recommended |
3c. Total Number of Nights in Past Month |
|
|
|
Query
|
scode |
Integer |
|
Recommended |
3d. Total Number of Admissions Past Mont |
|
|
|
Query
|
surfm31 |
Integer |
|
Recommended |
4. In the past month did you spend any nights in a nursing home for any reason (physical or emotional)? |
0;1
|
0=No; 1=Yes
|
|
Query
|
night2 |
Integer |
|
Recommended |
5a. Number of Nights in Nursing home |
|
|
srf5 |
Query
|
nurlevel |
Integer |
|
Recommended |
5b. Level of Nursing Home Care |
1;2
|
1 = Skilled; 2 = Intermediate
|
|
Query
|
surfm41 |
Integer |
|
Recommended |
6.In the past month did you spend any nights in a structured residence for any reason (physical or emotional)? |
0;1
|
0=No; 1=Yes
|
|
Query
|
night3 |
Integer |
|
Recommended |
7a. Number of Nights in Structured residence |
|
|
|
Query
|
levelc |
Integer |
|
Recommended |
7b. Level of Care |
1::4
|
1 = Halfway house; 2 = Board & Care; 3 = Supervised Apartment; 4=respite care
|
|
Query
|
surfm51 |
Integer |
|
Recommended |
8. In the last month, did you see a doctor or any other health care professional for an emotional or psychiatric problem? |
0;1
|
0=No; 1=Yes
|
srf6 |
Query
|
typecode |
Integer |
|
Recommended |
9a. Type Code for places from which patient may have received services |
1::16
|
1 = Community mental health center; 2 = Psychiatric clinic or private psychiatry; 3 = Family service or child guidance center 4 = Private Mental Health Professional; 5 = Alcohol or drug counseling center; 6 = Self-help group - e.g. AA CA NA; 7 = Day hospital or day treatment center; 8 = VA clinic; 9 = Vocational rehabilitation; 10 = Psychosocial rehabilitation program; 11 = Case Management-PACT; 12 = Other; 13 = Psychiatric contacts associated with; 14 = Clinical contacts associated with the; 15 = Study related psycho-educational visi 16 = Supportive employment
|
|
Query
|
numvisit |
Integer |
|
Recommended |
Number of Visits |
|
|
|
Query
|
avgmin |
Float |
|
Recommended |
9c. Average Minutes per Visit |
|
|
|
Query
|
surfm10 |
Integer |
|
Recommended |
10. In the past month, have you been to see a doctor or any other health care professional for any physical problems on an outpatient basis? |
0;1
|
0=No; 1=Yes
|
surfm21 |
Query
|
surfm10a |
Integer |
|
Recommended |
If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Private medical doctor |
|
|
|
Query
|
surfm10b |
Integer |
|
Recommended |
If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Private health care practitioner (non-M.D) |
|
|
|
Query
|
surfm10c |
Integer |
|
Recommended |
If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Outpatient clinic |
|
|
|
Query
|
surfm10d |
Integer |
|
Recommended |
If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Day surgery |
|
|
|
Query
|
surfm10e |
Integer |
|
Recommended |
If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Community Health Center |
|
|
|
Query
|
srfm10fa |
Integer |
|
Recommended |
If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Other |
|
|
|
Query
|
surfm10g |
Integer |
|
Recommended |
If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Emergency room (medical) |
|
|
|
Query
|
surfm10h |
Integer |
|
Recommended |
If YES, in which of the following settings did you have at least one outpatient visit for a physical or medical problem during the past month? Emergency room (psychiatric) |
|
|
|
Query
|
fseqno |
Integer |
|
Recommended |
Sequence Number |
0::999
|
The FSEQNO variable in the ADJ form has a special interpretation compared to other forms.
For example, ADJ FSEQNO of '1' can be thought of as being '001', FSEQNO of '2' can be thought of as
being '002', and FSEQNO of '3' can be thought of as being '003'.
The first digit of FSEQNO relates to the corresponding ENF sequence number at that visit and the third
digit relates to the specific adjudicator who completed the adjudication form.
|
|
Query
|
srfa1 |
Integer |
|
Recommended |
First, I want to ask you about times during the past month when you were an inpatient in a hospital,
do not include nursing homes or halfway house stays. Were you hospitalized for at least one night during the last month for any of the following reasons: medical or surgical problem, or a psychiatric or
substance abuse problem. |
0;1
|
0=No; 1=Yes
|
|
Query
|
srfa2a1 |
Integer |
|
Recommended |
1st event Reason |
0;1;2;3;4;5
|
0=No further events; 1=Medical problem (e.g. neurological); 2=Surgical problem; 3=Psychiatric (non-substance abuse); 4=Drug Abuse (not alcohol); 5=Alcohol abuse
|
|
Query
|
srfa2a2 |
Integer |
|
Recommended |
1st event Number of nights |
0::50
|
|
|
Query
|
srfa2a3 |
Integer |
|
Recommended |
1st event Provider Type |
1;2;3;4;5;6
|
1=State or county mental hospital; 2=Private psychiatric hospital; 3=Non-federal general hospital; 4=VA; 5=Multi-service community mental health center; 6=Substance abuse (detox facility)
|
|
Query
|
srfa2b1 |
Integer |
|
Recommended |
2nd event Reason |
0;1;2;3;4;5
|
0=No further events; 1=Medical problem (e.g. neurological); 2=Surgical problem; 3=Psychiatric (non-substance abuse); 4=Drug Abuse (not alcohol); 5=Alcohol abuse
|
|
Query
|
srfa2b2 |
Integer |
|
Recommended |
2nd event Number of nights |
0::50
|
|
|
Query
|
srfa2b3 |
Integer |
|
Recommended |
2nd event Provider type |
1;2;3;4;5;6
|
1=State or county mental hospital; 2=Private psychiatric hospital; 3=Non-federal general hospital; 4=VA; 5=Multi-service community mental health center; 6=Substance abuse (detox facility)
|
|
Query
|
srfa2c1 |
Integer |
|
Recommended |
3rd event Reason |
0;1;2;3;4;5
|
0=No further events; 1=Medical problem (e.g. neurological); 2=Surgical problem; 3=Psychiatric (non-substance abuse); 4=Drug Abuse (not alcohol); 5=Alcohol abuse
|
|
Query
|
srfa2c2 |
Integer |
|
Recommended |
3rd event Number of nights |
0::50
|
|
|
Query
|
srfa2c3 |
Integer |
|
Recommended |
3rd event provider type |
1;2;3;4;5;6
|
1=State or county mental hospital; 2=Private psychiatric hospital; 3=Non-federal general hospital; 4=VA; 5=Multi-service community mental health center; 6=Substance abuse (detox facility)
|
|
Query
|
srfa2d1 |
Integer |
|
Recommended |
4th event Reason |
0;1;2;3;4;5
|
1st event; 0=No further events; 1=Medical problem (e.g. neurological); 2=Surgical problem; 3=Psychiatric (non-substance abuse); 4=Drug Abuse (not alcohol); 5=Alcohol abuse
|
|
Query
|
srfa2d2 |
Integer |
|
Recommended |
4th event number of nights |
0::50
|
|
|
Query
|
srfa2d3 |
Integer |
|
Recommended |
4th event provider type |
1;2;3;4;5;6
|
1=State or county mental hospital; 2=Private psychiatric hospital; 3=Non-federal general hospital; 4=VA; 5=Multi-service community mental health center; 6=Substance abuse (detox facility)
|
|
Query
|
srfa2e1 |
Integer |
|
Recommended |
5th event Reason |
0;1;2;3;4;5
|
0=No further events; 1=Medical problem (e.g. neurological); 2=Surgical problem; 3=Psychiatric (non-substance abuse); 4=Drug Abuse (not alcohol); 5=Alcohol abuse
|
|
Query
|
srfa2e2 |
Integer |
|
Recommended |
5th event number of nights |
0::50
|
|
|
Query
|
srfa2e3 |
Integer |
|
Recommended |
5th event provider type |
1;2;3;4;5;6
|
1=State or county mental hospital; 2=Private psychiatric hospital; 3=Non-federal general hospital; 4=VA; 5=Multi-service community mental health center; 6=Substance abuse (detox facility)
|
|
Query
|
srfa3 |
Integer |
|
Recommended |
In the past month did you spend any nights in a nursing home for any reason, (Physical or emotional)? |
0;1
|
0=No; 1=Yes
|
|
Query
|
srfa3a1 |
Integer |
|
Recommended |
Number of nights |
00::50
|
Nursing home #1
|
|
Query
|
srfa3a2 |
Integer |
|
Recommended |
Level of care |
1;2
|
Nursing home #1; 1=Skilled; 2=Intermediate
|
|
Query
|
srfa3b1 |
Integer |
|
Recommended |
Number of nights |
00::50
|
Nursing home #2
|
|
Query
|
srfa3b2 |
Integer |
|
Recommended |
Level of care |
1;2
|
Nursing home #2; 1=Skilled; 2=Intermediate
|
|
Query
|
srfa3c1 |
Integer |
|
Recommended |
Number of nights |
00::50
|
Nursing home #3
|
|
Query
|
srfa3cb |
Integer |
|
Recommended |
Level of care |
1;2
|
Nursing home #3; 1=Skilled; 2=Intermediate
|
|
Query
|
srfa4 |
Integer |
|
Recommended |
In the past month did you spend any nights in a structured residence or halfway house for any reason (physical or emotional)? |
0;1
|
0=No; 1=Yes
|
|
Query
|
srfa4a1 |
Integer |
|
Recommended |
Number of nights |
00::50
|
Residence #1
|
|
Query
|
srfa4a2 |
Integer |
|
Recommended |
Level of care |
1;2;3
|
Residence #1; 1=Halfway House; 2=Board &Care; 3= Supervised apartment
|
|
Query
|
srfa4b1 |
Integer |
|
Recommended |
Number of nights |
00::50
|
Residence #2
|
|
Query
|
srfa4b2 |
Integer |
|
Recommended |
Level of care |
1;2;3
|
Residence#2; 1=Halfway House; 2=Board &Care; 3= Supervised apartment
|
|
Query
|
srfa4c1 |
Integer |
|
Recommended |
Number of nights |
00::50
|
Residence#3
|
|
Query
|
srfa4c2 |
Integer |
|
Recommended |
Level of care |
1;2;3
|
Residence#3; 1=Halfway House; 2=Board &Care; 3= Supervised apartment
|
|
Query
|
srfa5 |
Integer |
|
Recommended |
Next, I want to ask you about outpatient visits for help with drug or alcohol abuse, emotional or psychiatric problems. In the last month, did you see a doctor or any other health care professional for an emotional or psychiatric problem? This should include visits for problems related to alcohol or drug use. |
0;1
|
0=No; 1=Yes
|
|
Query
|
srfa5a1 |
Integer |
|
Recommended |
Services. Commnity Mental Health Clinic Services |
0;1
|
0=No; 1=Yes
|
surfm17e |
Query
|
srfa5a2 |
Integer |
|
Recommended |
Number of visits |
0::50
|
Commnity Mental Health Clinic Services
|
srfa7 |
Query
|
srfa5a3 |
Integer |
|
Recommended |
average minutes/visit |
000::999
|
Commnity Mental Health Clinic Services
|
|
Query
|
srfa5b1 |
Integer |
|
Recommended |
Services. Psychiatric Clinic |
0;1
|
0=No; 1=Yes
|
surfm17f |
Query
|
srfa5b2 |
Integer |
|
Recommended |
number of visits |
0::100; -99
|
Psychiatric Clinic; -99=NK
|
srfa8 |
Query
|
srfa5b3 |
Integer |
|
Recommended |
average minutes/visit |
000::999; -99
|
Psychiatric Clinic; -99=NK
|
|
Query
|
srfa5c1 |
Integer |
|
Recommended |
Services. Family Service or Guardian Agency |
0;1
|
0=No; 1=Yes
|
surfm17g |
Query
|
srfa5c2 |
Integer |
|
Recommended |
number of visits |
0::50
|
Family Service or Guardian Agency
|
srfa9 |
Query
|
srfa5c3 |
Integer |
|
Recommended |
average minutes/visit |
000::999
|
Family Service or Guardian Agency
|
|
Query
|
srfa5d1 |
Integer |
|
Recommended |
services. Private Mental Health Professional |
0;1
|
0=No; 1=Yes
|
surfm17h |
Query
|
srfa5d2 |
Integer |
|
Recommended |
number of visits |
0::50
|
Private Mental Health Professional (psychiatrist,
social worker, psychologist, visiting nurse,etc...)
|
srfa10, surfm21b |
Query
|
srfa5d3 |
Integer |
|
Recommended |
average minutes/visit |
000::999
|
Private Mental Health Professional (psychiatrist,
social worker, psychologist, visiting nurse,etc...)
|
|
Query
|
srfa5e1 |
Integer |
|
Recommended |
services. Alcohol or Drug Counseling |
0;1
|
0=No; 1=Yes
|
surfm17i |
Query
|
srfa5e2 |
Integer |
|
Recommended |
number of visits |
0::50
|
Alcohol or Drug Counseling
|
srfa11 |
Query
|
srfa5e3 |
Integer |
|
Recommended |
average minutes/visit |
000::999
|
Alcohol or Drug Counseling
|
|
Query
|
srfa5f1 |
Integer |
|
Recommended |
services. Self-Help Group |
0;1
|
0=No; 1=Yes
|
surfm17j |
Query
|
srfa5f2 |
Integer |
|
Recommended |
number of visits |
0::60
|
Self-Help Group (AA, NA, Peer Support)
|
srfa12 |
Query
|
srfa5f3 |
Integer |
|
Recommended |
Self-Help Group (AA, NA, Peer Support) average minutes/visit |
000::999
|
Self-Help Group (AA, NA, Peer Support)
|
|
Query
|
srfa5g1 |
Integer |
|
Recommended |
Services. Day Hospital/Day Treatment Center |
0;1
|
0=No; 1=Yes
|
surfm17k |
Query
|
srfa5g2 |
Integer |
|
Recommended |
number of visits |
0::50
|
Day Hospital/Day Treatment Center
|
srfa13 |
Query
|
srfa5g3 |
Integer |
|
Recommended |
average number of minutes |
000::999
|
Day Hospital/Day Treatment Center
|
|
Query
|
srfa5h1 |
Integer |
|
Recommended |
services. VA Clinic |
0;1
|
0=No; 1=Yes
|
surfm17l |
Query
|
srfa5h2 |
Integer |
|
Recommended |
number of visits |
0::50
|
VA Clinic
|
srfa14 |
Query
|
srfa5h3 |
Integer |
|
Recommended |
average minutes/visit |
000::999
|
VA Clinic
|
|
Query
|
srfa5i1 |
Integer |
|
Recommended |
services. Vocational Rehabilitation |
0;1
|
0=No; 1=Yes
|
surfm17m |
Query
|
srfa5i2 |
Integer |
|
Recommended |
number of visits |
0::50
|
Vocational Rehabilitation
|
srfa15 |
Query
|
srfa5i3 |
Integer |
|
Recommended |
average minutes/visit |
000::999
|
Vocational Rehabilitation
|
|
Query
|
srfa5j1 |
Integer |
|
Recommended |
services. Psychosocial Rehabilitation Program |
0;1
|
0=No; 1=Yes
|
surfm17n |
Query
|
srfa5j2 |
Integer |
|
Recommended |
number of visits |
0::50
|
Psychosocial Rehabilitation Program
|
srfa16 |
Query
|
srfa5j3 |
Integer |
|
Recommended |
average minutes/visit |
000::999
|
Psychosocial Rehabilitation Program
|
|
Query
|
srfa5k1 |
Integer |
|
Recommended |
services. Supportive employment |
0;1
|
0=No; 1=Yes
|
surfm17b |
Query
|
srfa5k2 |
Integer |
|
Recommended |
number of visits |
0::50
|
Supportive employment
|
|
Query
|
srfa5k3 |
Integer |
|
Recommended |
average minutes/visit |
000::999
|
Supportive employment
|
|
Query
|
srfa5l1 |
Integer |
|
Recommended |
services. Case Management/PACT |
0;1
|
0=No; 1=Yes
|
surfm17a |
Query
|
srfa5l2 |
Integer |
|
Recommended |
number of visits |
0::50
|
Case Management/PACT (note: If included in previous categories do not double count)
|
srfa17 |
Query
|
srfa5l3 |
Integer |
|
Recommended |
average minutes/visit |
000::999
|
Case Management/PACT (note: If included in previous categories do not double count)
|
|
Query
|
srfa5m1 |
Integer |
|
Recommended |
services. Clinical contacts with study psychiatrists |
0;1
|
0=No; 1=Yes
|
surfm17c |
Query
|
srfa5m2 |
Integer |
|
Recommended |
number of visits |
0::50
|
Clinical contacts with study psychiatrists
|
|
Query
|
srfa5m3 |
Integer |
|
Recommended |
average minutes/visit |
000::999
|
Clinical contacts with study psychiatrists
|
|
Query
|
srfa5n1 |
Integer |
|
Recommended |
services. Clinical contacts with study research staff for non-study clinical care |
0;1
|
0=No; 1=Yes
|
surfm17d |
Query
|
srfa5n2 |
Integer |
|
Recommended |
number of visits |
0::50
|
Clinical contacts with study research staff for non-study clinical care
|
|
Query
|
srfa5n3 |
Integer |
|
Recommended |
average minutes/visit |
000::999
|
Clinical contacts with study research staff for non-study clinical care
|
|
Query
|
srfa5o1 |
Integer |
|
Recommended |
Services |
0;1
|
0=No; 1=Yes
|
|
Query
|
srfa5o2 |
Integer |
|
Recommended |
number of visits |
0::100; -99
|
Other services; -99=NK
|
srfa18 |
Query
|
srfa5o3 |
Integer |
|
Recommended |
average minutes/visit |
000::999; -99
|
Other services; -99=NK
|
|
Query
|
srfa6a |
Integer |
|
Recommended |
PrivateMedicalDoctor number of visits |
0::50
|
|
srfa20 |
Query
|
srfa6b |
Integer |
|
Recommended |
Private Health Care Practitioner (Non-M.D.) number of visits |
0::50
|
|
srfa21 |
Query
|
srfa6c |
Integer |
|
Recommended |
OutpatientClinic number of visits |
0::50
|
|
srfa22, surfm21c |
Query
|
srfa6d |
Integer |
|
Recommended |
Day surgery number of visits |
0::50
|
|
srfa23, surfm21d |
Query
|
srfa6e |
Integer |
|
Recommended |
Community Health Center number of visits |
0::50
|
|
srfa24, surfm21e |
Query
|
srfa6f |
Integer |
|
Recommended |
Other number of visits |
0::50
|
|
srfa25 |
Query
|
srfa6g |
Integer |
|
Recommended |
Emergency Room (Medical) number of visits |
0::200
|
|
srfa26, surfm21f |
Query
|
srfa6h |
Integer |
|
Recommended |
Emergency Room (Psychiatric) number of visits |
0::50
|
|
srfa27, surfm21g |
|
version_form |
String |
121
|
Recommended |
Form used/assessment name |
|
|
vers |
Query
|
daysrz |
Integer |
|
Recommended |
days since randomization |
|
|
srfa0b |
Query
|
srfa19 |
Integer |
|
Recommended |
Clinical visits associated with project (*) |
0::50
|
Do not include clinical visits exclusively for research data collection. This category includes both physician and non-physician visits for clinical care.
|
|
Query
|
srf1 |
Integer |
|
Recommended |
Medical problem: number of nights |
0::50
|
|
|
|
srf1a |
String |
30
|
Recommended |
Medical problem: Provider Type |
|
S-Legitimately skipped
|
|
Query
|
srf2 |
Integer |
|
Recommended |
Surgical problem: Number of nights |
0::50
|
|
|
|
srf2a |
String |
30
|
Recommended |
Surgical problem: Provider Typer |
|
S-Legitimately skipped
|
|
Query
|
srf3 |
Integer |
|
Recommended |
Psychiatric problem: Number of nights |
0::50
|
|
|
|
srf3a |
String |
50
|
Recommended |
Psychiatric problem: Provider Type |
|
S-Legitimately skipped
|
|
Query
|
srf4 |
Integer |
|
Recommended |
Substance abuse problem: Number of nights |
0::50
|
|
|
|
srf4a |
String |
30
|
Recommended |
Substance abuse problem: Provider Type |
|
S-Legitimately skipped
|
|
Query
|
surfm01 |
Integer |
|
Recommended |
Was [patient] hospitalized for at least one night for any of the following reasons during the last month? |
0;1
|
0=No; 1=Yes
|
|
Query
|
surfm01a |
Integer |
|
Recommended |
Medical Problem |
1; 0
|
1=Yes; 0=No
|
|
Query
|
copyid |
Integer |
|
Recommended |
Copy ID for multi-copy forms |
|
The case report form used to create this file is a multi- copy form, meaning more than one copy of it can be completed at any one visit. For example, a patient with three adverse events to report at a single visit would have 3 copies of the form at that visit, one for each adverse event. The data file will have three unique records for this patient at this visit. COPYID identifies the order in which the forms were completed at a visit.
|
|
Query
|
surfm12 |
Integer |
|
Recommended |
In the last month, did [patient] receive special help, services, or equipment related to Alzheimer's Disease or its effect? |
0;1
|
0=No; 1=Yes
|
|
Query
|
surfm12a |
Integer |
|
Recommended |
Social day care / adult day care? |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12b |
Integer |
|
Recommended |
In home respite care |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12c |
Integer |
|
Recommended |
Case Management |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12d |
Integer |
|
Recommended |
Congregate Meals |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12e |
Integer |
|
Recommended |
Home delivered meals |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12f |
Integer |
|
Recommended |
Visiting nurses services |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12g |
Integer |
|
Recommended |
Physical therapy |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12h |
Integer |
|
Recommended |
Speech/occupational therapy |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12i |
Integer |
|
Recommended |
Homemaker/ housekeeping services |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12j |
Integer |
|
Recommended |
Live-in Caregiver Services |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12k |
Integer |
|
Recommended |
Companion services |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12l |
Integer |
|
Recommended |
Client education training services |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12m |
Integer |
|
Recommended |
Client support group |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12n |
Integer |
|
Recommended |
Transportation services: ambulance |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12o |
Integer |
|
Recommended |
Transportation services to health services (taxi, escort, but not family) |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12p |
Integer |
|
Recommended |
Delivery of adaptive or assistive equipment or medical supplies |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12q |
Integer |
|
Recommended |
Clinical contacts associated with research staff of this project |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm12r |
Integer |
|
Recommended |
Psychiatric contacts associated with study medication (Physician related visits) |
1; 0
|
In the past month, did patient attend/use any of these for help with Alzheimer's Disease or its consequences?; 1=Yes; 0=No
|
|
Query
|
surfm13 |
Integer |
|
Recommended |
Type Code |
1::18
|
1=Social day care adult day care; 2=In home respite care; 3=Case management; 4=Congregate meals
5=Home delivered meals; 6=Visiting nurses services; 7=Physical therapy; 8=Speech/occupational therapy; 9=Homemaker/Housekeeping services; 10=Live-in caregiver services; 11=Companion services; 12=Client education training services; 13=Client support group; 14=Transportation services: ambulance; 15=Transportation servic+D1es to health ser; 16=Delivery of adaptive or assistive equ; 17=Clinical contacts associated with res; 18=Psychiatric contacts associated with
|
|
Query
|
surfm13a |
Integer |
|
Recommended |
Number of Visits |
1::31
|
|
surfm14 |
Query
|
surfm13b |
Integer |
|
Recommended |
Average Minutes per
Visit |
0::999
|
|
surfm15 |
Query
|
surfm16 |
Integer |
|
Recommended |
In the last month, did [patient] see a doctor or any other health care professional for an emotional or psychiatric problem? |
0;1
|
0=No; 1=Yes
|
|
Query
|
surfm16a |
Integer |
|
Recommended |
Number of visits in the past month |
1::31
|
|
|
Query
|
surfm18 |
Integer |
|
Recommended |
Type Code |
1;2;3;4;5;6;7;8;9;10;11;12;13;14
|
1 = Case management/PACT; 2=Supportive employment; 3=Psychiatric contacts associated with s; 4=Clinical contacts associated with rese; 5=Community mental health center; 6=Psychiatric clinic or Private Psychiat; 7=Family service or child guidance agenc; 8=Private mental health professional [a; 9=Alcohol or drug counseling; 10=Self-help group [e.g., AA, CA, NA]; 11=Day Hospital/Day Treatment Center; 12=VA Clinic; 13=Vocational rehabilitation; 14=Psychosocial rehabilitation program
|
|
Query
|
surfm18a |
Integer |
|
Recommended |
Number of Visits: |
1::31
|
|
surfm19 |
Query
|
surfm18b |
Integer |
|
Recommended |
Average minutes per visit |
0::999
|
|
surfm20 |
Query
|
surfm21a |
Integer |
|
Recommended |
Private medical doctor |
0::99
|
|
|
Query
|
monthsbl |
Float |
|
Recommended |
Actual number of months from Baseline |
|
|
|
Query
|
days_baseline |
Integer |
|
Recommended |
Days since baseline |
|
|
|
Query
|
surm005b |
Integer |
|
Recommended |
Nursing home provider |
1::7
|
1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; 4 = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility; 7=none of the above
|
|
Query
|
surm006b |
Integer |
|
Recommended |
Halfway house or staffed residence provider |
1::7
|
1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; VA = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility; 7=none of the above
|
|
Query
|
surm007 |
Integer |
|
Recommended |
Emergency Room (past 30 days), Medical reason |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm007b |
Integer |
|
Recommended |
Emergency Room (past 30 days), Medical reason; average duration, minutes |
|
|
|
Query
|
surm008 |
Integer |
|
Recommended |
Emergency Room (Psychiatric/Substance Use Reason) |
|
|
|
Query
|
surm008b |
Integer |
|
Recommended |
Emergency Room (Psychiatric/Substance Use Reason), average duration, minutes |
|
|
|
Query
|
surm009 |
Integer |
|
Recommended |
Who do you live with? Where do you usually sleep at night? |
1::7
|
1=Living alone � independent living situation; 2=Supported living arrangement � may include other residents, some supervision but not daily on site management; 3=Structured environment � e.g., board and care, group home, halfway house; VA=Family of origin � e.g., parents, grandparents, siblings or other relative; 5=Family of orientation � e.g., spouse, children; 6=Homeless shelter or on the street; 7=Other living situation
|
|
|
currestx |
String |
100
|
Recommended |
Other living situation, describe |
|
|
|
Query
|
studntyn |
Integer |
|
Recommended |
Is the client currently a student |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm011 |
Integer |
|
Recommended |
If yes- Are you full-time or Part-time |
1;2
|
1=Fulltime; 2= part-time
|
|
Query
|
surm012 |
Integer |
|
Recommended |
What is the type of school or classes you are attending |
1::5
|
1 =High school - include both for HS diploma and GED; 2 College or University - that offers Bachelors or advanced degree; 3= Community College - that offers Associate degree; VA =Vocational or Technical School - that offers Certificates such as culinary arts. such as automotive, electrical, plumbing, computer. IT (Information Technology) cosmetology; 5= Other school that offers a Certificate or skill training
|
|
|
surm012a |
String |
100
|
Recommended |
Other school that offers a Certificate or skill training (specify) |
|
|
|
Query
|
surm013 |
Integer |
|
Recommended |
If yes - How many days per week are you scheduled to go to classes |
|
|
|
Query
|
dworked |
Integer |
|
Recommended |
How many days in the past month have you actually worked for pay? |
|
|
|
Query
|
hworked |
Integer |
|
Recommended |
About how many hours a week do/did you usually work? |
|
999 = Missing
|
|
Query
|
earnweek |
Integer |
|
Recommended |
About how much did you earn per week? (round to dollars, no cents) |
|
|
|
Query
|
surfq2 |
Integer |
|
Recommended |
IB. In addition to the above earnings, during the past month, have you done any casual employment or day jobs, such as yard work or babysitting over a few days for which you got paid? |
0;1
|
0 = No; 1 = Yes
|
|
Query
|
surfq2a |
Integer |
|
Recommended |
About how much did you earn doing day jobs in the past month? (round to dollars, no cents) |
|
|
|
Query
|
surfq3 |
Integer |
|
Recommended |
During the past month, have you done any kind of volunteer work (such as working at a hospital or a school)? |
0;1
|
0 = No; 1 = Yes
|
|
Query
|
surfq3a |
Integer |
|
Recommended |
About how many days did you do volunteer work? |
|
|
|
Query
|
surfq3b |
Integer |
|
Recommended |
On a day that you did volunteer work, about how many hours per day did you do volunteer work? |
|
|
|
Query
|
surm019 |
Integer |
|
Recommended |
During the last 30 days, have you been looking for work |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm041 |
Integer |
|
Recommended |
In the past 30 days, how many visits did you attend at these programs for an emotionalor psychiatric problem, or for an alcohol or drug problem? Psychiatrist |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm041a |
Integer |
|
Recommended |
Psychiatrist. Number of outpatient visits of this type |
|
|
|
Query
|
surm041b |
Integer |
|
Recommended |
Psychiatrist. Average duration of this type of visit, minutes |
|
|
|
Query
|
surm042 |
Integer |
|
Recommended |
In the past 30 days, how many visits did you attend at these programs for an emotionalor psychiatric problem, or for an alcohol or drug problem? Nurse Practitioner |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm042a |
Integer |
|
Recommended |
Nurse Practitioner. Number of outpatient visits of this type |
|
|
|
Query
|
surm042b |
Integer |
|
Recommended |
Nurse Practitioner. Average duration of this type of visit, minutes |
|
|
|
Query
|
surm043 |
Integer |
|
Recommended |
Were you asked to record your symptoms and side effects before you met with your psychiatrist or nurse practitioner |
0::3
|
2=No; 1=Yes; 3= DK; 0=Not prescribed any psychiatric medication
|
|
Query
|
surm044c |
Integer |
|
Recommended |
get a job in the community or furthering your education. How many visits were in community (non-clinic) settings? |
|
|
|
Query
|
surm045 |
Integer |
|
Recommended |
Has your family met with a mental health provider to help them understand and address your situation? |
0;1
|
0=No; 1=Yes
|
|
Query
|
outpprof |
Integer |
|
Recommended |
Outpatient Mental Health treatment: Professional treatment: Number of visits |
|
|
|
Query
|
surm045b |
Integer |
|
Recommended |
mental health provider. Average duration of this type of visit, minutes |
|
|
|
Query
|
surm046 |
Integer |
|
Recommended |
Have you had individual sessions with a mental health provider that help you work on your goals and look positively towards the future? |
|
|
|
Query
|
surm046a |
Integer |
|
Recommended |
individual sessions with a mental health provider. Number of outpatient visits of this type |
|
|
|
Query
|
surm046b |
Integer |
|
Recommended |
individual sessions with a mental health provider. Average duration of this type of visit, minutes |
|
|
|
Query
|
surm048c |
Integer |
|
Recommended |
Case Management. How many visits were in community (non-clinic) settings? |
|
|
|
Query
|
surm049 |
Integer |
|
Recommended |
Peer support/counseling dont include Alcoholics Anonymous(AA) or Narcotics Anonymous (NA) |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm049a |
Integer |
|
Recommended |
Peer Support. Number of outpatient visits of this type |
|
|
|
Query
|
surm049b |
Integer |
|
Recommended |
Peer Support. Average duration of this type of visit, minutes |
|
|
|
Query
|
surm052 |
Integer |
|
Recommended |
Club House |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm052a |
Integer |
|
Recommended |
Club House. Number of days you visited a club house |
|
|
|
|
q14_4_s13 |
String |
100
|
Recommended |
Other service: Other Specify |
|
|
|
Query
|
surm059 |
Integer |
|
Recommended |
In the past 30 days, how many visits did you attend at these clinics for medical problems? Private Medical Doctor |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm060 |
Integer |
|
Recommended |
In the past 30 days, how many visits did you attend at these clinics for medical problems? Private Health Care Practitioner (Non-M.D.) |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm061 |
Integer |
|
Recommended |
In the past 30 days, how many visits did you attend at these clinics for medical problems? Outpatient Clinic |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm062 |
Integer |
|
Recommended |
In the past 30 days, how many visits did you attend at these clinics for medical problems? Day/Outpatient surgery |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm063 |
Integer |
|
Recommended |
In the past 30 days, how many visits did you attend at these clinics for medical problems? Community Health Center |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm064 |
Integer |
|
Recommended |
In the past 30 days, how many visits did you attend at these clinics for medical problems? Other |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm064b |
Integer |
|
Recommended |
Other. Average duration of this type of visit, minutes |
|
|
|
|
surm064c |
String |
100
|
Recommended |
Other, specify |
|
|
|
Query
|
surm065 |
Integer |
|
Recommended |
In the past 30 days how many days have you used tobacco, number of days |
|
|
|
Query
|
surm071 |
Integer |
|
Recommended |
INPATIENT CARE. Since our last assessment. Psychiatric program |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm071a |
Integer |
|
Recommended |
INPATIENT CARE. Since our last assessment. Psychiatric program. Total Number of ADDITIONAL nights |
|
|
|
Query
|
surm071b |
Integer |
|
Recommended |
INPATIENT CARE. Since our last assessment. Psychiatric program. Provider |
1::7
|
1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; 4 = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility; 7=none of the above
|
|
Query
|
surm072 |
Integer |
|
Recommended |
INPATIENT CARE. Since our last assessment. Medical Surgical program |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm072a |
Integer |
|
Recommended |
INPATIENT CARE. Since our last assessment. Medical Surgical program. Total Number of ADDITIONAL nights |
|
|
|
Query
|
surm072b |
Integer |
|
Recommended |
INPATIENT CARE. Since our last assessment. Medical Surgical program Provider |
1::7
|
1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; 4 = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility; 7=none of the above
|
|
Query
|
surm073 |
Integer |
|
Recommended |
INPATIENT CARE. Since our last assessment. Emergency Room Psychiatric/Substance use Reason |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm073a |
Integer |
|
Recommended |
INPATIENT CARE. Since our last assessment. Emergency Room Psychiatric/Substance use Reason Total Number of ADDITIONAL visits |
|
|
|
Query
|
surm073b |
Integer |
|
Recommended |
INPATIENT CARE. Since our last assessment. Emergency Room Psychiatric/Substance use Reason Provider |
1::7
|
1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; 4 = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility; 7=none of the above
|
|
Query
|
surm074 |
Integer |
|
Recommended |
INPATIENT CARE. Since our last assessment. Emergency Room Medical/Surgical Reason |
0;1
|
0=No; 1=Yes
|
|
Query
|
surm074a |
Integer |
|
Recommended |
INPATIENT CARE. Since our last assessment. Emergency Room Medical/Surgical Reason Total Number of ADDITIONAL visits |
|
|
|
Query
|
surm074b |
Integer |
|
Recommended |
INPATIENT CARE. Since our last assessment. Emergency Room Medical/Surgical Reason Provider |
1::7
|
1 = State and county mental hospital; 2 = Private psychiatric hospital; 3 = Non-federal general hospital; 4 = VA; 5 = Multi-service community mental health; 6 = Substance abuse/detox facility; 7=none of the above
|
|
Query
|
gap_days |
Integer |
|
Recommended |
NUMBER OF DAYS GREATER THAN or LESS THAN 30 between data collection |
|
|
|
Query
|
wrkfrpay |
Integer |
|
Recommended |
Work for Pay? |
0;1;9;777
|
0=No; 1=Yes; 9=NK; 777=Not applicable
|
|