Adolescent Survey (Web version) - Spanish

Traumatic Brain Injury (TBI) Surveillance System

E-12 Adolescent Survey (web) -- Spanish

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 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 when year 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 2018)


PRESYMMU (Did not enter an injury description or date 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 “Injury A”)


INTENTX (Multiple injuries w/o INJOPNB entered)


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


BIKEX


BIKE1X








BIKE4X


MVX


MV3X




MV2X


MV6X


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 “Un entrenador” in DBYWHOA)


PRETELL


NOTELLWHY



FUNCS


FUNCSA


END




CLOSE


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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSumner, Julia
File Modified0000-00-00
File Created2021-01-15

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