Adolescent Survey (Web version) - English

Traumatic Brain Injury (TBI) Surveillance System

E-6 Adolescent Survey (web) -- English

Adolescent Survey - Adolescent 13-17 years of age

OMB: 0920-1240

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LANDING PAGE



LANG


Page seen upon clicking “STOP” button


RECALL


INJ

INJ soft validation if no answer


INJN


INJN soft validation if no answer







PREJOG (No injuries examined)


PREJOG (At least one injury examined)


INJ2










INJ2 soft validation if no answer


INJN2



INJN2 soft validation if no answer







INJNTOT (Single injury)


INJNTOT (Multiple injuries)


PREINTX (Single injury)











PREINTX (Multiple injuries)


PREINTX2


PREINTX3













INJOPNB


INJOPNB2


INJOPNB3








YEAR



YEAR soft validation if not 2016-2017.

MONTH


MONTH soft validation if future date is entered based on month and year.









MONTHA/SIXMO


MONTHB/ONEYR


PRESYMMU (Entered “Injury A” as description of most recent injury, dated April 2018)



PRESYMMU (Entered “Injury B” as description of 2nd most recent injury, without specifying date)


Alternative: PRESYMMU (Entered “Injury B” as description of 2nd most recent injury, dated March 2017)


PRESYMMU (Did not enter an injury description or month for 3rd most recent injury)











PRESYM


SYM1 (Single injury)


SYM1 (Multiple injuries)







SYM1-SYM12 soft validation when no answer.

SYM2


SYM3






SYM3A

SYM3A soft validation when no answer

PRESYM4


SYM4


SYM4A

SYM4A-SYM8A soft validation when no answer.

SYM5

SYM5A

SYM6








SYM6A

SYM7


SYM7A







SYM8


SYM8A

PRESYM9








SYM9


SYM10


SYM11








SYM12


SRRX

ACTSELX







INTENTX (Single injury)


INTENTX (Multiple injuries, w/INJOPNB entered)


INTENTX (Multiple injuries w/o INJOPNB entered)


TXMOST (Entered “Injury A” as description of most recent injury)

BIKEX


BIKE1X







BIKE4X


MVX



MV7X




CAUSEX


HELMETX

HELMET1X









SYMSTILL


SYMRECA


SYMRECA soft validation for out of range days based on injury month and year.

SYMRECA soft validation for out of range weeks based on injury month and year.

SYMRECA soft validation for out of range months based on injury month and year.

DASSESSED


DBYWHOA


DBYWHOB (Selected “A coach” in DBYWHOA)


PRETELL

NOTELLWHY

FUNCS

















FUNCSA


END

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSumner, Julia
File Modified0000-00-00
File Created2021-01-20

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