pedsql quality of life and cardiac module inventories and ... · pedsql™ quality of life and...

PedsQL™ Quality of Life and Cardiac Module Inventories and Conditions and Problems Questionnaire [CHSS Data Center]

for CHSS Data Center Studies, Age & Consent/Assent Status

Version Date: 01 Mar 2016 of 13

PedsQL™ Quality of Life and Cardiac Module Inventories and Conditions and Problems

Questionnaire [CHSS Data Center] for CHSS Data Center Studies, Age & Consent/Assent Status

PedsQL™ Inventory

and

Conditions and Problems

Questionnaire

Blue =

Subject/Participant

Orange =

Parent/Guardian

Age

of Subject

Consent/Assent Status

PedsQL™

Adult Quality of Life Inventory

Version 4.0

ADULT REPORT PedsQL 4.0 - (Adult)

Copyright © 1998 JW Varni, Ph.D.

2/07

PedsQL-4.0-Core – United States/English – Original version

PedsQL-4.0-Core-Adult_AU4.0_eng-USori

≥ 26

years old

Consent [Adult Subject]

PedsQL™

Cardiac Module

Version 3.0

ADULT REPORT

PedsQL 3.0 - (Adult) Cardiac


08/00

PedsQL™

Adult Quality of Life Inventory

Version 4.0

PARENT REPORT for ADULTS PedsQL 4.0 - Parent (Adult)


01/00


PedsQL-4.0-Core-PAdult_AU4.0_eng-USori

≥ 26

years old

Consent [Parent/Guardian]

and

Assent [Adult Subject] or

explanation (e.g., confirmation

that Adult Subject lacks

capacity to provide assent)

AND



capacity to consent for

him/herself)

[should not be used if Subject has

consented for him/herself, unless

Subject aware that Parent/

PedsQL™

Cardiac Module

Version 3.0

PARENT REPORT for ADULTS

PedsQL 3.0 – Parent (Adult) Cardiac


08/00




Guardian may complete this report]

PedsQL™

Young Adult Quality of Life Inventory

Version 4.0

YOUNG ADULT REPORT (ages 18-25)

PedsQL 4.0 - (18-25)


2/07


PedsQL-4.0-Core-Yad_AU4.0_eng-USori

18-25

years old

Consent [Adult Subject]

PedsQL™


Version 4.0 - English (Canada)


PedsQL 4.0 - (18-25)


2/07

PedsQL Core Young Adult - Canada/English -

Version of 08 Apr 14 - Mapi.

ID 7702 / PedsQL-4.0-Core-Yad_AU4.0_eng-CA.doc

PedsQL™

Cardiac Module

Version 3.0


PedsQL 3.0 - (18-25) Cardiac


08/00

PedsQL™

Inventaire de la qualité de vie des jeunes adultes

Version 4.0 – Canadian French

QUESTIONNAIRE DESTINÉ AUX JEUNES ADULTES

(18 à 25 ans)

PedsQL 4.0 - (18-25)


PedsQL™ 4.0 Generic Core Scale - Young Adult (18-25) -

Canada/French - Version of 11 Dec 08 -

Mapi Research Institute.

ID4875/PedsQL-4.0-Core-Yad_AU4.0_fre-CA.doc

PedsQL™

Cuestionario de Calidad de Vida en Adultos Jóvenes




Version 4.0 - Spanish (United States)

REPORTE DE ADULTOS JÓVENES (edades 18-25)

PedsQL 4.0 - (18-25)


2/07

PedsQL-4.0-Core-Yad - United States/Spanish -

Version of 30 Nov 15 - Mapi.

ID050236 / PedsQL-4.0-Core-Yad-AU4.0_spa-US.doc

PedsQL™


Version 4.0

PARENT REPORT for YOUNG ADULTS (ages 18-25)

PedsQL 4.0 - Parent (18-25)


01/00


PedsQL-4.0-Core-PYA_AU4.0_eng-USori

18-25

years old


and

Assent [Adult Subject] or



capacity to provide assent)

AND



capacity to consent for

him/herself)



Subject aware that Parent/


PedsQL™

Cardiac Module

Version 3.0

PARENT REPORT for YOUNG ADULTS (ages 18-25)

PedsQL 3.0 – Parent (18-25) Cardiac


08/00

PedsQL™

Pediatric Quality of Life Inventory

Version 4.0

TEEN REPORT (ages 13-18)

PedsQL 4.0 - (13-18)


01/00

PedsQL -4.0-Core – United States/English – Original version

PedsQL-4.0-Core-A_AU4.0_eng-USori

13-17

years old


and

Assent [Subject]

[cannot be used if Subject

lacks capacity to provide

assent]

OR

Consent [Subject with capacity

to consent for him/herself]

[should not be used if Subject is

≥ 18 years old (i.e., YOUNG ADULT

REPORT should be used)]

PedsQL™

Paediatric Quality of Life Inventory


TEEN REPORT (ages 13-18) PedsQL 4.0 - (13-18)





01/00

PedsQL 4.0-Core-A - Canada/English -

Version of 13 Jan14 – Mapi.

ID7106 / PedsQL-4.0-Core-A_AU4.0_eng-CA.doc

PedsQL™

Cardiac Module

Version 3.0

TEEN REPORT (ages 13-18) PedsQL 3.0 (13-18) Cardiac


08/00

PedsQL™

Inventaire de la qualité de vie pédiatrique

Version 4.0 – français (Canada)

QUESTIONNAIRE DESTINÉ AUX ADOLESCENTS

(13 à 18 ans)

PedsQL 4.0 – (13-18)


(PedsQL4-Module-A-cafq.doc)

JANUARY 2003

PedsQL™

Cuestionario Pediátrico de Calidad de Vida


REPORTE DE ADOLESCENTES (edades 13-18) PedsQL 4.0 - (13-18)


01/00

PedsQL-4.0-Core-A - United States/Spanish -

Version of 14 May 14 - Mapi.

ID7106 / PedsQL-4.0-Core-A_AU4.0_spa-US.doc

PedsQL™


Version 4.0

PARENT REPORT for TEENS (ages 13-18) PedsQL 4.0 - Parent (13-18)


01/00


PedsQL-4.0-Core-PA_AU4.0_eng-USori

13-17

years old


and

Assent [Subject] or


that Subject lacks capacity to

provide assent)



Subject aware that Parent/ PedsQL™





Version 4.0 English (Canada)

PARENT REPORT for TEENS (ages 13-18) PedsQL 4.0 Parent (13-18)


01/00

PedsQL-4.0-Core-PA - Canada/English -

Version of 28 Jan 13 – MAPI Institute.

ID7063/PedsQL-4.0-Core-PA_AU4.0_eng-CA.doc


PedsQL™

Cardiac Module

Version 3.0

PARENT REPORT for TEENS (ages 13-18)

PedsQL 3.0 - Parent (13-18) Cardiac


08/00

Conditions and Problems Questionnaire

[CHSS Data Center]

[Parent/Guardian]

Version Date: 22 October 2015

PedsQL™



QUESTIONNAIRE DESTINÉ AUX PARENTS

D’ADOLESCENTS (13 à 18 ans)

PedsQL 4.0 – Parent (13-18)


(PedsQL4-Module-PA-cafq.doc)

JANUARY 2003

PedsQL™



REPORTE DE PADRES sobre ADOLESCENTES

(edades 13-18)



01/00

PedsQL-4.0-Core-PA - United States/Spanish -





ID7106 / PedsQL-4.0-Core-PA_AU4.0_spa-US.doc

PedsQL™


Version 4.0

CHILD REPORT (ages 8-12)

PedsQL 4.0 - (8-12)


01/00


PedsQL-4.0-Core-C_AU4.0_eng-USori

8-12

years old


and

Assent [Subject]

[cannot be used if Subject

lacks capacity to provide

assent]

PedsQL™

Paediatric Quality of Life Inventory


CHILD REPORT (ages 8-12)

PedsQL 4.0 - (8-12)


01/00

PedsQL 4.0-Core-C - Canada/English -

Version of 13 Jan 14 - Mapi.

ID7106 / PedsQL 4.0-Core-C_AU4.0_eng-CA.doc

PedsQL™

Cardiac Module

Version 3.0

CHILD REPORT (ages 8-12) PedsQL 3.0 (8-12) Cardiac


08/00

PedsQL™



QUESTIONNAIRE DESTINÉ AUX ENFANTS (8 à 12 ans)

PedsQL 4.0 – (8-12)


(PedsQL4-Module-C-cafq.doc)

JANUARY 2003

PedsQL™



REPORTE DE NIÑOS(AS) (edades 8-12)

PedsQL 4.0 - Child (8-12)





01/00

PedsQL-4.0-Core-C - United States/Spanish -


ID7106 / PedsQL-4.0-Core-C_AU4.0_spa-US.doc

PedsQL™


Version 4.0

PARENT REPORT for CHILDREN (ages 8-12) PedsQL 4.0 - Parent (8-12)


01/00


PedsQL-4.0-Core-PC_AU4.0_eng-USori

8-12

years old


and

Assent [Subject] or



provide assent)

PedsQL™



PARENT REPORT for CHILDREN (ages 8-12) PedsQL 4.0 Parent (8-12)


01/00

PedsQL-4.0-Core-PC - Canada/English -

Version of 28 Jan 13 - MAPI Institute.

ID7063 / PedsQL-4.0-Core-PC_AU4.0_eng-CA.doc

PedsQL™

Cardiac Module

Version 3.0

PARENT REPORT for CHILDREN (ages 8-12)



08/00


[CHSS Data Center]

[Parent/Guardian]


PedsQL™



QUESTIONNAIRE DESTINÉ AUX PARENTS D’ENFANTS




(8 à 12 ans)



(PedsQL4-Module-PC-cafq.doc)

JANUARY 2003

PedsQL™



REPORTE DE PADRES sobre NIÑOS(AS) (edades 8-12)



PedsQL-4.0-Core-PC - United States/Spanish -


ID7106 / PedsQL-4.0-Core-PC_AU4.0_spa-US.doc

PedsQL™


Version 4.0

PARENT REPORT for YOUNG CHILDREN (ages 5-7)



01/00


PedsQL-4.0-Core-PYC_AU4.0_eng-USori

5-7

years old


and

Assent [Subject] or



provide assent)

PedsQL™






01/00

PedsQL-4.0-Core-PYC - Canada/English -

Version of 28 Jan 13 - MAPI Institute.

ID7063 / PedsQL-4.0-Core-PYC_AU4.0_eng-CA.doc

PedsQL™

Cardiac Module

Version 3.0




03/01





[CHSS Data Center]

[Parent/Guardian]


PedsQL™



QUESTIONNAIRE DESTINÉ AUX PARENTS DE JEUNES

ENFANTS (5 à 7 ans)



(PedsQL4-Module-PYC-cafq.doc)

JANUARY 2003

PedsQL™



REPORTE DE PADRES sobre NIÑOS(AS) (edades 5-7) PedsQL 4.0 - Parent (5-7)


01/00

PedsQL-4.0-Core-PYC - United States/Spanish -


ID7822 / PedsQL-4.0-Core-PYC_AU4.0_spa-US.doc

PedsQL™

Módulo cardíaco Spanish (US)

Version 3.0

REPORTE DE LOS PADRES sobre NIÑOS DE 5 A 7 AÑOS

DE EDAD


Copyright © 1998 JW Varni, Ph.D

03/01

PedsQL-3.0-Cardiac-PYC_AU3.0_spa-US_Academic-Translation

PedsQL™


Version 4.0

PARENT REPORT for TODDLERS (ages 2-4) PedsQL 4.0 - Parent (2-4)


01/00

PedsQL-4.0-Core - United States/English – Original version

2-4

years old





PedsQL-4.0-Core-PT_AU4.0_eng-USori

PedsQL™



PARENT REPORT for TODDLERS (ages 2-4) PedsQL 4.0 - Parent (2-4)


01/00

PedsQL-4.0-Core-PT - Canada/English -

Version of 28 Jan 13 – MAPI Institute.

ID7063 / PedsQL-4.0-Core-PT_AU4.0_eng-CA.doc

PedsQL™

Cardiac Module

Version 3.0

PARENT REPORT for TODDLERS (ages 2-4) PedsQL 3.0 - Parent (2-4) Cardiac


08/00

PedsQL™



QUESTIONNAIRE DESTINÉ AUX PARENTS DE BAMBINS

(2 à 4 ans)



(PedsQL4-Module-PT-cafq.doc)

JANUARY 2003

PedsQL™



INFORME DE LOS PADRES sobre NIÑOS(AS) (edades 2-4) PedsQL 4.0 Parent (2-4)


PedsQL-4.0-Core-PT - United States/Spanish -

Version of 13 Mar 15 - Mapi.

ID036132 / PedsQL-4.0-Core-PT_AU4.0_spa-US.doc

PedsQL™

Módulo cardíaco Spanish (US)

Version 3.0




REPORTE DE LOS PADRES sobre NIÑOS DE 2 a 4 AÑOS

DE EDAD



08/00

PedsQL-3.0-Cardiac-PT_AU3.0_spa-US_Academic-Translation

PedsQL™

Pediatric Quality of Life Inventory Infant Scales

PARENT REPORT for INFANTS (ages 13-24 months)

PedsQL™ Infant Scales 13-24 months


1/10

13-24

months old


PedsQL™


English (Canada)




1/10

PedsQL-Infant-(13-24Months) - Canada/English -

Version of 31 Jul 13 - Mapi.

ID7346 / PedsQL-Infant-(13-24Months)_AU1.0_eng-CA.doc

PedsQL™


French (Canada)

Questionnaire au sujet des enfants en bas âge

QUESTIONNAIRE DESTINÉ AUX PARENTS D’ENFANTS EN

BAS ÂGE (13 à 24 mois)



1/10

PedsQL-Infant-(13-24Months) - Canada/French -

Version of 09 Aug 13 - Mapi.

PedsQL-Infant-(13-24Months)_AU1.0_fra-CA.doc

PedsQL™


Cuestionarios sobre bebés

Spanish (United States)

REPORTE de PADRES sobre BEBÉS

(edades de 13 a 24 meses)




PedsQL™ Cuestionarios sobre bebés de 13 a 24 meses


1/10

PedsQL-Infant-(13-24Months) - United States/Spanish -


ID7346 / PedsQL-Infant-(13-24Months)_AU1.0_spa-US.doc

PedsQL™





1/10

1-12

months old


PedsQL™


English (Canada)




1/10

PedsQL-Infant-(1-12Months) - Canada/English -

Version of 31 Jul 13 - Mapi.

ID7346 / PedsQL-Infant-(1-12Months)_AU1.0_eng-CA.doc

PedsQL™


French (Canada)

Questionnaire au sujet des enfants en bas âge

QUESTIONNAIRE DESTINÉ AUX PARENTS D’ENFANTS EN

BAS ÂGE (1 à 12 mois)



1/10

PedsQL-Infant-(1-12Months) - Canada/French -


ID7346 / PedsQL-Infant-(1-12Months)_AU1.0_fra-CA.doc

PedsQL™


Cuestionarios sobre bebés

Spanish (United States)

REPORTE de PADRES sobre BEBÉS

(edades de 1 a 12 meses)

PedsQL™ Cuestionarios sobre bebés de 1 a 12 meses





1/10

PedsQL-Infant-(1-12Months) - United States/Spanish -


ID7346 / PedsQL-Infant-(1-12Months)_AU1.0_spa-US.doc

Please Note:

(1) The language of the Inventory and Questionnaire (English, Spanish, French) to be used will be determined by:

- availability of the questionnaire

- the language used for the Consent/Assent process, as applicable

(2) English language:

- Parents-Guardians of Participants age 5-17 years, at US Institutions, will complete the standard Conditions and

Problems [CHSS Data Center] questionnaire [which is English (Canada)] and Participants/Parents-Guardians will complete

the standard PedsQL™ (English) questionnaires [which are English (United States)].

- Parents-Guardians of Participants age 5-17 years, at Canadian Institutions, will complete the standard Conditions and

Problems [CHSS Data Center] questionnaire [which is English (Canada)] and the Participants/Parents-Guardians will

complete the standard PedsQL™ English (Canada) version, if available; otherwise, the standard PedsQL™ (English)

questionnaires will be used [which are English (United States)].

pedsql quality of life and cardiac module inventories and ... · pedsql™ quality of life and...

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