ID

16963

Description

ODM derived from: http://research.uic.edu/qip/toolbox/case-report-forms-crf. Template Name: Social History Form. QIP Case Report Forms, UIC Quality Improvement CRF, Office of the Vice Chancellor for Research. Center for Clinical and Translational Science, UIC University of Illinois at Chicago.

Link

http://research.uic.edu/qip/toolbox/case-report-forms-crf

Keywords

Versions (1)
  1. 8/17/16 8/17/16 -
Uploaded on

August 17, 2016

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Social History Form: UIC Quality Improvement CRF

English

Social History Form: UIC Quality Improvement CRF

1 forms  
General Information
Description

General Information

Protocol Title
Description

Protocol Title

Data type

text

Site Number
Description

Site Number

Data type

integer

Subject ID
Description

Subject ID

Data type

integer

Visit Date
Description

Visit Date

Data type

date

Study Visit
Description

Study Visit

Data type

text

Social History Form
Description

Social History Form

1. Highest Level of Education
Description

1. Highest Level of Education

Data type

text

2. Occupation
Description

2. Occupation

Data type

text

Occupation
Description

Occupation

Data type

text

Occupation: If retired, please specify date
Description

Occupation

Data type

date

3a. Language(s) in which subject is fluent: English
Description

3a. Language

Data type

boolean

Language(s) in which subject is fluent: Spanish
Description

Language

Data type

boolean

Language(s) in which subject is fluent: Chinese
Description

Language

Data type

boolean

Language(s) in which subject is fluent: Tagalog
Description

Language

Data type

boolean

Language(s) in which subject is fluent: Korean
Description

Language

Data type

boolean

Language(s) in which subject is fluent: Russian
Description

Language

Data type

boolean

Language(s) in which subject is fluent: Polish
Description

Language

Data type

boolean

Language(s) in which subject is fluent: Other
Description

Language

Data type

boolean

If Other, please specify
Description

Language

Data type

text

3b. Language in which subject requests study visits to be conducted
Description

3b. Language in which subject requests study visits to be conducted

Data type

text

If Other, please specify
Description

Language

Data type

text

4. Tobacco/Nicotine History
Description

If Yes, Complete information for ALL that are applicable

Data type

boolean

Cigarettes
Description

Tobacco/Nicotine History

Data type

boolean

Cigarettes: Frequency
Description

Tobacco/Nicotine History

Data type

text

Cigarettes: Start Date
Description

Tobacco/Nicotine History

Data type

date

Cigarettes: Continuing
Description

Tobacco/Nicotine History

Data type

boolean

Cigarettes: Stop Date
Description

Tobacco/Nicotine History

Data type

date

Cigars
Description

Tobacco/Nicotine History

Data type

boolean

Pipe
Description

Tobacco/Nicotine History

Data type

boolean

Chewing tobacco/snuff
Description

Tobacco/Nicotine History

Data type

boolean

Other
Description

Tobacco/Nicotine History

Data type

boolean

If Other, please specify
Description

Tobacco/Nicotine History

Data type

text

Cigars/Pipe/Chewing tobacco/snuff/Other: Frequency
Description

Tobacco/Nicotine History

Data type

text

Cigars/Pipe/Chewing tobacco/snuff/Other: Start Date
Description

Tobacco/Nicotine History

Data type

date

Cigars/Pipe/Chewing tobacco/snuff/Other: Continuing
Description

Tobacco/Nicotine History

Data type

boolean

Cigars/Pipe/Chewing tobacco/snuff/Other: Stop Date
Description

Tobacco/Nicotine History

Data type

date

5. Alcohol History
Description

If Yes, Complete information for ALL that are applicable.

Data type

boolean

Beer
Description

Alcohol History

Data type

boolean

Beer: Frequency
Description

Alcohol History

Data type

text

Beer: Start Date
Description

Alcohol History

Data type

date

Beer: Continuing
Description

Alcohol History

Data type

boolean

Beer: Stop Date
Description

Alcohol History

Data type

date

Wine
Description

Alcohol History

Data type

boolean

Wine: Frequency
Description

Alcohol History

Data type

text

Wine: Start Date
Description

Alcohol History

Data type

date

Wine: Continuing
Description

Alcohol History

Data type

boolean

Wine: Stop Date
Description

Alcohol History

Data type

date

Hard Liquor
Description

Alcohol History

Data type

boolean

Hard Liquor: Frequency
Description

Alcohol History

Data type

text

Hard Liquor: Start Date
Description

Alcohol History

Data type

date

Hard Liquor: Continuing
Description

Alcohol History

Data type

boolean

Hard Liquor: Stop Date
Description

Alcohol History

Data type

date

6. Illicit Substances History
Description

If Yes, Complete information for ALL that are applicable

Data type

boolean

Marijuana
Description

Illicit Substances History

Data type

boolean

Marijuana: Frequency
Description

Illicit Substances History

Data type

text

Marijuana: Start Date
Description

Illicit Substances History

Data type

date

Marijuana: Continuing
Description

Illicit Substances History

Data type

boolean

Marijuana: Stop Date
Description

Illicit Substances History

Data type

date

Cocaine
Description

Illicit Substances History

Data type

boolean

Cocaine: Frequency
Description

Illicit Substances History

Data type

text

Cocaine: Start Date
Description

Illicit Substances History

Data type

date

Cocaine: Continuing
Description

Illicit Substances History

Data type

boolean

Cocaine: Stop Date
Description

Illicit Substances History

Data type

date

Other (specify)
Description

Illicit Substances History

Data type

boolean

Other: Frequency
Description

Illicit Substances History

Data type

text

Other: Start Date
Description

Illicit Substances History

Data type

date

Other: Continuing
Description

Illicit Substances History

Data type

boolean

Other: Stop Date
Description

Illicit Substances History

Data type

date

If Other, please specify
Description

Illicit Substances History

Data type

text

Completed by (initials)
Description

Completed by (initials)

Data type

text

Date completed
Description

Date completed

Data type

date

Back to the top of the page

Similar models

Social History Form: UIC Quality Improvement CRF

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
General Information
Protocol Title
Item
Protocol Title
text
Site Number
Item
Site Number
integer
Subject ID
Item
Subject ID
integer
Visit Date
Item
Visit Date
date
Study Visit
Item
Study Visit
text
Item Group
Social History Form
Item
1. Highest Level of Education
text
1. Highest Level of Education
Code List
1. Highest Level of Education
CL Item
Grade school graduate (1)
CL Item
Some high school (2)
CL Item
High school graduate (3)
CL Item
Some collage (4)
CL Item
College graduate (5)
CL Item
Post college graduate (6)
2. Occupation
Item
2. Occupation
text
Item
Occupation
text
2. Occupation
Code List
Occupation
CL Item
Full Time  (1)
CL Item
Part-time (2)
CL Item
Retired___ (3)
CL Item
Unknown (4)
Occupation
Item
Occupation: If retired, please specify date
date
3a. Language
Item
3a. Language(s) in which subject is fluent: English
boolean
Language
Item
Language(s) in which subject is fluent: Spanish
boolean
Language
Item
Language(s) in which subject is fluent: Chinese
boolean
Language
Item
Language(s) in which subject is fluent: Tagalog
boolean
Language
Item
Language(s) in which subject is fluent: Korean
boolean
Language
Item
Language(s) in which subject is fluent: Russian
boolean
Language
Item
Language(s) in which subject is fluent: Polish
boolean
Language
Item
Language(s) in which subject is fluent: Other
boolean
Language
Item
If Other, please specify
text
Item
3b. Language in which subject requests study visits to be conducted
text
3b. Language in which subject requests study visits to be conducted
Code List
3b. Language in which subject requests study visits to be conducted
CL Item
English (1)
CL Item
Spanish (2)
CL Item
Chinese (3)
CL Item
Tagalog (4)
CL Item
Korean (5)
CL Item
Russian (6)
CL Item
Polish (7)
CL Item
Other (8)
Language
Item
If Other, please specify
text
4. Tobacco/Nicotine History
Item
4. Tobacco/Nicotine History
boolean
Tobacco/Nicotine History
Item
Cigarettes
boolean
Tobacco/Nicotine History
Item
Cigarettes: Frequency
text
Tobacco/Nicotine History
Item
Cigarettes: Start Date
date
Tobacco/Nicotine History
Item
Cigarettes: Continuing
boolean
Tobacco/Nicotine History
Item
Cigarettes: Stop Date
date
Tobacco/Nicotine History
Item
Cigars
boolean
Tobacco/Nicotine History
Item
Pipe
boolean
Tobacco/Nicotine History
Item
Chewing tobacco/snuff
boolean
Tobacco/Nicotine History
Item
Other
boolean
Tobacco/Nicotine History
Item
If Other, please specify
text
Tobacco/Nicotine History
Item
Cigars/Pipe/Chewing tobacco/snuff/Other: Frequency
text
Tobacco/Nicotine History
Item
Cigars/Pipe/Chewing tobacco/snuff/Other: Start Date
date
Tobacco/Nicotine History
Item
Cigars/Pipe/Chewing tobacco/snuff/Other: Continuing
boolean
Tobacco/Nicotine History
Item
Cigars/Pipe/Chewing tobacco/snuff/Other: Stop Date
date
5. Alcohol History
Item
5. Alcohol History
boolean
Alcohol History
Item
Beer
boolean
Alcohol History
Item
Beer: Frequency
text
Alcohol History
Item
Beer: Start Date
date
Alcohol History
Item
Beer: Continuing
boolean
Alcohol History
Item
Beer: Stop Date
date
Alcohol History
Item
Wine
boolean
Alcohol History
Item
Wine: Frequency
text
Alcohol History
Item
Wine: Start Date
date
Alcohol History
Item
Wine: Continuing
boolean
Alcohol History
Item
Wine: Stop Date
date
Alcohol History
Item
Hard Liquor
boolean
Alcohol History
Item
Hard Liquor: Frequency
text
Alcohol History
Item
Hard Liquor: Start Date
date
Alcohol History
Item
Hard Liquor: Continuing
boolean
Alcohol History
Item
Hard Liquor: Stop Date
date
6. Illicit Substances History
Item
6. Illicit Substances History
boolean
Illicit Substances History
Item
Marijuana
boolean
Illicit Substances History
Item
Marijuana: Frequency
text
Illicit Substances History
Item
Marijuana: Start Date
date
Illicit Substances History
Item
Marijuana: Continuing
boolean
Illicit Substances History
Item
Marijuana: Stop Date
date
Illicit Substances History
Item
Cocaine
boolean
Illicit Substances History
Item
Cocaine: Frequency
text
Illicit Substances History
Item
Cocaine: Start Date
date
Illicit Substances History
Item
Cocaine: Continuing
boolean
Illicit Substances History
Item
Cocaine: Stop Date
date
Illicit Substances History
Item
Other (specify)
boolean
Illicit Substances History
Item
Other: Frequency
text
Illicit Substances History
Item
Other: Start Date
date
Illicit Substances History
Item
Other: Continuing
boolean
Illicit Substances History
Item
Other: Stop Date
date
Illicit Substances History
Item
If Other, please specify
text
Completed by (initials)
Item
Completed by (initials)
text
Date completed
Item
Date completed
date
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial