FITBIR Demographics



Sports-Related Concussion Demographics FormForm AdministrationWho filled out this form?Select one. If other is selected, please write in response: FORMCHECKBOX Brother FORMCHECKBOX Chart/Medical Record FORMCHECKBOX Daughter FORMCHECKBOX Father FORMCHECKBOX Friend FORMCHECKBOX Mother FORMCHECKBOX Participant/Subject FORMCHECKBOX Physician FORMCHECKBOX Sister FORMCHECKBOX Son FORMCHECKBOX Spouse FORMCHECKBOX Other, specify: Patient Demographics QuestionsWhat is the subject’s date of birth?YYYY-MM-DDWrite in response.What is the subject’s gender?Select one: FORMCHECKBOX Female FORMCHECKBOX Male FORMCHECKBOX Not reported FORMCHECKBOX Unknown FORMCHECKBOX Unspecified4. Sex at birth FORMCHECKBOX ?XX; XX FORMCHECKBOX ?XY; XY FORMCHECKBOX ?XXX; XXX FORMCHECKBOX ?XYY; XYY FORMCHECKBOX ?XXY; XXY FORMCHECKBOX Unspecified; Undifferentiated/ Indeterminant/ Intersex FORMCHECKBOX ?Unknown FORMCHECKBOX Other, specify:5. Sexual orientation FORMCHECKBOX Heterosexual FORMCHECKBOX Gay/Lesbian FORMCHECKBOX Bisexual FORMCHECKBOX Unknown FORMCHECKBOX Not Reported FORMCHECKBOX ?OtherWhat is the subject’s handedness preference, or dominant hand?Select one: FORMCHECKBOX Both FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX UnknownWhat is the subject’s racial background (as defined by OMB)?Select all that apply. FORMCHECKBOX American Indian or Alaska Native FORMCHECKBOX Asian FORMCHECKBOX Black or African-American FORMCHECKBOX Native Hawaiian or Other Pacific Islander FORMCHECKBOX White FORMCHECKBOX Not Reported FORMCHECKBOX UnknownWhat is the subject’s racial background (expanded categories)?Select all that apply. FORMCHECKBOX Alaskan Native FORMCHECKBOX Black African FORMCHECKBOX Black African American FORMCHECKBOX Black Afro Caribbean FORMCHECKBOX Far Eastern Asian FORMCHECKBOX Hawaiian FORMCHECKBOX Inuit FORMCHECKBOX North American Indian FORMCHECKBOX Pacific Islander FORMCHECKBOX South/Central American Indian FORMCHECKBOX South Asian FORMCHECKBOX Western Asian FORMCHECKBOX White African FORMCHECKBOX White Australian FORMCHECKBOX White European FORMCHECKBOX White Middle Eastern FORMCHECKBOX White North American FORMCHECKBOX White South American FORMCHECKBOX Other FORMCHECKBOX Not ReportedWhat is the subject’s ethnic background?Select one: If other is selected, please write in response: FORMCHECKBOX Hispanic or Latino FORMCHECKBOX Not Hispanic or Latino FORMCHECKBOX Not reported FORMCHECKBOX Unknown FORMCHECKBOX Other, specify:What is the subject’s birth country (use ISO code)?For full list of codes, see BirthCntryISOCode variable in the data dictionary and provide information in the Other categorySelect one: If other is selected, please write in response: FORMCHECKBOX Australia (AU) FORMCHECKBOX Canada (CA) FORMCHECKBOX Mexico (MX) FORMCHECKBOX United Kingdom (GB) FORMCHECKBOX USA (US) FORMCHECKBOX Other, specify:What is the subject’s birth country name?Write in response. What is the subject’s current country of residence?For full list of codes, see CntryResdnceISOCode variable in the data dictionary and provide information in the Other categorySelect one: If other is selected, please write in response: FORMCHECKBOX Australia (AU) FORMCHECKBOX Canada (CA) FORMCHECKBOX Mexico (MX) FORMCHECKBOX United Kingdom (GB) FORMCHECKBOX USA (US) FORMCHECKBOX Other, specify:What is the subject’s current country of residence name?Write in response.What is the subject’s primary language (use ISO code)?Select one: If other is selected, please write in response: FORMCHECKBOX eng (English) FORMCHECKBOX spa (Spanish) FORMCHECKBOX sgn (Sign Language) FORMCHECKBOX chi (Chinese) FORMCHECKBOX fre (French) FORMCHECKBOX ger (German) FORMCHECKBOX Other, specify What are the ISO codes for each language the subject can speak fluently? The ISO codes represent the international codes for different countries.Write in response.Please list each language the subject can speak fluently: Write in response.What are the ISO codes for each language the subject can write fluently? Write in response.Please list each language the subject can write fluently: Write in response.FITBIR Demographics Parent, Guardian, or Caregiver InfoWhat is the relationship between the person who acts as the primary caregiver for the subject and the subject? Select all that apply. If other is selected, please write in response: FORMCHECKBOX Adoptive father FORMCHECKBOX Adoptive mother FORMCHECKBOX Adoptive parents FORMCHECKBOX Biological father FORMCHECKBOX Biological father - not a primary caregiver FORMCHECKBOX Biological mother FORMCHECKBOX Biological mother - not a primary caregiver FORMCHECKBOX Biological parents FORMCHECKBOX Child FORMCHECKBOX Grandfather FORMCHECKBOX Grandmother FORMCHECKBOX Home aide FORMCHECKBOX Legal guardian FORMCHECKBOX Long-term care staff FORMCHECKBOX Parent FORMCHECKBOX Relative FORMCHECKBOX Self FORMCHECKBOX Sibling FORMCHECKBOX Spouse or partner FORMCHECKBOX Stepfather FORMCHECKBOX Stepmother FORMCHECKBOX Stepparent FORMCHECKBOX Unknown FORMCHECKBOX Other, specify:What are the living statuses of the subject's parents? Select all that apply: FORMCHECKBOX Father alive FORMCHECKBOX Father deceased FORMCHECKBOX Father unknown FORMCHECKBOX Mother alive FORMCHECKBOX Mother deceased FORMCHECKBOX Mother unknownWhat is the parent, guardian, or caregiver’s gender?Select one: FORMCHECKBOX Female FORMCHECKBOX Male FORMCHECKBOX Not reported FORMCHECKBOX Unknown FORMCHECKBOX UnspecifiedWhat is the parent, guardian, or caregiver’s race, based on the OBM race standards?Select all that apply: FORMCHECKBOX American Indian or Alaska Native FORMCHECKBOX Asian FORMCHECKBOX Black or African-American FORMCHECKBOX Native Hawaiian or Other Pacific Islander FORMCHECKBOX White FORMCHECKBOX Not Reported FORMCHECKBOX UnknownWhat is the parent, guardian, or caregiver’s race, using expanded race categories?Select all that apply: FORMCHECKBOX Alaskan Native FORMCHECKBOX Black African FORMCHECKBOX Black African American FORMCHECKBOX Black Afro Caribbean FORMCHECKBOX Far Eastern Asian FORMCHECKBOX Hawaiian FORMCHECKBOX Inuit FORMCHECKBOX North American Indian FORMCHECKBOX Pacific Islander FORMCHECKBOX South/Central American Indian FORMCHECKBOX South Asian FORMCHECKBOX Western Asian FORMCHECKBOX White African FORMCHECKBOX White Australian FORMCHECKBOX White European FORMCHECKBOX White Middle Eastern FORMCHECKBOX White North American FORMCHECKBOX White South American FORMCHECKBOX Other FORMCHECKBOX Not ReportedWhat is the parent, guardian, or caregiver’s ethnicity?Select one. If other is selected, please write in response: FORMCHECKBOX Hispanic or Latino FORMCHECKBOX Not Hispanic or Latino FORMCHECKBOX Not reported FORMCHECKBOX Unknown FORMCHECKBOX Other, specify:What is the parent, guardian, or caregiver’s birth country ISO code?For full list of codes, see BirthCntryISOCode variable in the data dictionarySelect one. If other is selected, please write in response: FORMCHECKBOX Australia (AU) FORMCHECKBOX Canada (CA) FORMCHECKBOX Mexico (MX) FORMCHECKBOX United Kingdom (GB) FORMCHECKBOX USA (US) FORMCHECKBOX Other, specify:What is the parent, guardian, or caregiver’s birth country name? Write in response ................
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