NACC Uniform Data Set (UDS) FTLD Module Data Template For FOLLOW-UP Visit Packet Version 2.0, January 2012 Copyright 2013 University of Washington Created and published by the FTLD work group of the ADC Program (David Knopman, MD, Chair) and the National Alzheimer s Coordinating Center (Walter A. Kukull, PhD, Director). All rights reserved. This publication was funded by the National Institutes of Health through the National Institute on Aging (Cooperative Agreement U01 AG016976). NOTE: Version 2 is NOT the most current version of the FTLD Moudle forms and is no longer used for data submission. For the most current version, please visit http:// www.alz.washington.edu.
FTLD Module to the Uniform Data Set Data Template for the Follow-up Visit Packet Preface This template is designed to help the Data Cores at the Alzheimer s Disease Centers develop software for submitting FTLD data to NACC. In this template, data elements are organized by form and, within the form, by item number. For each data element, the template lists the element name, element type, columns for ASCII file submission, and item number. This template is needed only for file submission. Centers using web data entry will not need this template. A more detailed description of each data element is found in the Data Element Dictionary for the FTLD Follow-up Visit Packet. Please note: The first 10 data elements are the same for each form, and hence for each template. These elements which are required are shaded on the template. For ASCII fixed-format files, exactly one blank space is required between the data fields of adjacent variables. Although a data field may in some cases contain one or more blanks, the required separator blank must still be included. Column assignments and column alignment must be maintained. For SAS files, all data elements must be present in the file. For tab-delimited files, all fields must be separated by one tab. For comma-delimited files, all fields must be separated by one comma. Fields containing commas must be contained in quotation marks. In some cases, the item number shown in the template does not appear in the form. This is true for most Other (specify) text items and dates.
Coding for form header (first 10 data elements on each form) PACKET = FF (The letter F, for the Follow-up Visit FTLD Module) FORMID = Form ID (I.e., Z1F, A3A, A3F, etc.) FORMVER = 2 Although this is the first version of the FTLD forms, the FORMVER is 2 because the FTLD Module was initially created to be used with Version 2 of the UDS. ADCID = Center ID The same number used in the MDS and NP data for your Center; see the Data Element Dictionary for the FTLD Module or the UDS for a list of Center IDs. PTID = Patient ID Follow your Center s patient ID scheme. For each subject, patient ID: must be unique within the data set from your Center no duplicate Patient IDs are permitted; must be the same for each visit in the FTLD Module; and must be the same PTID used for that subject in all the NACC databases (UDS, MDS, and NP). PTID cannot be changed once it has been assigned by your Center. Because this is a character field, you must include or exclude leading zeros to match ID numbers across all data sets. VISITMO VISITDAY = Actual date of the interview; cannot precede 01/01/2012 VISITYR VISITNUM = Visit ID Assigned by your Center; need not start with 1 INITIALS = Examiner s initials (Initials of the person conducting the interview)
Form Z1F Form Checklist 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 1 45 45 FTDA3AFS N 1a 2 47 48 FTDA3AFR N 1b 60 50 109 FTDA3AFC C 1c 1 111 111 FTDA3FS N 2a 2 113 114 FTDA3FR N 2b 60 116 175 FTDA3FC C 2c 1 177 177 FTDC4FS N 3a 2 179 180 FTDC4FR N 3b 60 182 241 FTDC4FC C 3c 1 243 243 FTDC5FS N 4a 2 245 246 FTDC5FR N 4b 60 248 307 FTDC5FC C 4c 1 309 309 FTDC6FS N 5a 2 311 312 FTDC6FR N 5b 60 314 373 FTDC6FC C 5c NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 1
Form A3aF Record of Consent for Biologic Specimen Use 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 1 45 45 FTDRELCO N 1 4 47 50 FTDSIBBY N 1 4 52 55 FTDCHDBY N 1 1 57 57 FTDSTORE N 1a 1 59 59 FTDSLEAR N 1b 1 61 61 FTDCOMME N 1c NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 2
Form A3F Family History: Affected Family Members 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 1 45 45 FTDFA3F1 N 1 1 47-47 FTDAFF N 1a 1 49-49 FTDMUTAT N 1b 1 51-51 FTDPMUT N 1c 60 53-112 FTDPMUTX C 1c1 1 114 114 FTDMCLAB N 1d 1 116 116 FTDMRLAB N 1e 1 118 118 FTDMFAMR N 1f 1 120 120 FTDMOTH N 1g 60 122 181 FTDMOTHX C 1g1 1 183 183 FTDFA3F2 N 2 1 185 185 FTDMOMN N 2aa 3 187 189 FTDMOMP N 2ab 1 191 191 FTDMOME N 2ac 3 193 195 FTDMOMA N 2ad 1 197 197 FTDDADN N 2ba 3 199 201 FTDDADP N 2bb 1 203 203 FTDDADE N 2bc 3 205 207 FTDDADA N 2bd 2 209 209 FTDFA3F3 N 3 2 211 212 FTDBSAM N 3aa NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 3
Form A3F family history: affected family members CONTINUED 4 214 217 FTDBSA N 3aa 1 219 219 FTDNSA N 3ab 3 221 223 FTDPSA N 3ac 1 225 225 FTDMSA N 3ad 3 227 229 FTDASA N 3ae 2 231 232 FTDBSBM N 3ba 4 234 237 FTDBSB N 3ba 1 239 239 FTDNSB N 3bb 3 241 243 FTDPSB N 3bc 1 245 245 FTDMSB N 3bd 3 247 249 FTDASB N 3be 2 251 252 FTDBSCM N 3ca 4 254 257 FTDBSC N 3ca 1 259 259 FTDNSC N 3cb 3 261 263 FTDPSC N 3cc 1 265 265 FTDMSC N 3cd 3 267 269 FTDASC N 3ce 2 271 272 FTDBSDM N 3da 4 274 277 FTDBSD N 3da 1 279 279 FTDNSD N 3db 3 281 283 FTDPSD N 3dc 1 285 285 FTDMSD N 3dd 3 287 289 FTDASD N 3de 2 291 292 FTDBSEM N 3ea 4 294 297 FTDBSE N 3ea 1 299 299 FTDNSE N 3eb 3 301 303 FTDPSE N 3ec 1 305 305 FTDMSE N 3ed 3 307 309 FTDASE N 3ee 2 311 312 FTDBSFM N 3fa 4 314 317 FTDBSF N 3fa 1 319 319 FTDNSF N 3fb 3 321 323 FTDPSF N 3fc 1 325 325 FTDMSF N 3fd 3 327 329 FTDASF N 3fe NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 4
Form A3F family history: affected family members CONTINUED 2 331 332 FTDBSGM N 3ga 4 334 337 FTDBSG N 3ga 1 339 339 FTDNSG N 3gb 3 341 343 FTDPSG N 3gc 1 345 345 FTDMSG N 3gd 3 347 349 FTDASG N 3ge 2 351 352 FTDBSHM N 3ha 4 354 357 FTDBSH N 3ha 1 359 359 FTDNSH N 3hb 3 361 363 FTDPSH N 3hc 1 365 365 FTDMSH N 3hd 3 367 369 FTDASH N 3he 2 371 372 FTDBSIM N 3ia 4 374 377 FTDBSI N 3ia 1 379 379 FTDNSI N 3ib 3 381 383 FTDPSI N 3ic 1 385 385 FTDMSI N 3id 3 387 389 FTDASI N 3ie 2 391 392 FTDBSJM N 3ja 4 394 397 FTDBSJ N 3ja 1 399 399 FTDNSJ N 3jb 3 401 403 FTDPSJ N 3jc 1 405 405 FTDMSJ N 3jd 3 407 409 FTDASJ N 3je 2 411 412 FTDBSKM N 3ka 4 414 417 FTDBSK N 3ka 1 419 419 FTDNSK N 3kb 3 421 423 FTDPSK N 3kc 1 425 425 FTDMSK N 3kd 3 427 429 FTDASK N 3ke 2 431 432 FTDBSLM N 3la 4 434 437 FTDBSL N 3la 1 439 439 FTDNSL N 3lb 3 441 443 FTDPSL N 3lc 1 445 445 FTDMSL N 3ld NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 5
Form A3F family history: affected family members CONTINUED 3 447 449 FTDASL N 3le 2 451 452 FTDBSMM N 3ma 4 454 457 FTDBSM N 3ma 1 459 459 FTDNSM N 3mb 3 461 463 FTDPSM N 3mc 1 465 465 FTDMSM N 3md 3 467 469 FTDASM N 3me 2 471 471 FTDFA3F4 N 4 2 473 474 FTDBCAM N 4aa 4 476 479 FTDBCA N 4aa 1 481 481 FTDNCA N 4ab 3 483 485 FTDPCA N 4ac 1 487 487 FTDMCA N 4ad 3 489 491 FTDACA N 4ae 2 493 494 FTDBCBM N 4ba 4 496 499 FTDBCB N 4ba 1 501 501 FTDNCB N 4bb 3 503 505 FTDPCB N 4bc 1 507 507 FTDMCB N 4bd 3 509 511 FTDACB N 4be 2 513 514 FTDBCCM N 4ca 4 516 519 FTDBCC N 4ca 1 521 521 FTDNCC N 4cb 3 523 525 FTDPCC N 4cc 1 527 527 FTDMCC N 4cd 3 529 531 FTDACC N 4ce 2 533 534 FTDBCDM N 4da 4 536 539 FTDBCD N 4da 1 541 541 FTDNCD N 4db 3 543 545 FTDPCD N 4dc 1 547 547 FTDMCD N 4dd 3 549 551 FTDACD N 4de 2 553 554 FTDBCEM N 4ea 4 556 559 FTDBCE N 4ea 1 561 561 FTDNCE N 4eb NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 6
Form A3F family history: affected family members CONTINUED 3 563 565 FTDPCE N 4ec 1 567 567 FTDMCE N 4ed 3 569 571 FTDACE N 4ee 2 573 574 FTDBCFM N 4fa 4 576 579 FTDBCF N 4fa 1 581 581 FTDNCF N 4fb 3 583 585 FTDPCF N 4fc 1 587 587 FTDMCF N 4fd 3 589 591 FTDACF N 4fe 2 593 594 FTDBCGM N 4ga 4 596 599 FTDBCG N 4ga 1 601 601 FTDNCG N 4gb 3 603 605 FTDPCG N 4gc 1 607 607 FTDMCG N 4gd 3 609 611 FTDACG N 4ge 2 613 614 FTDBCHM N 4ha 4 616 619 FTDBCH N 4ha 1 621 621 FTDNCH N 4hb 3 623 625 FTDPCH N 4hc 1 627 627 FTDMCH N 4hd 3 629 631 FTDACH N 4he 2 633 634 FTDBCIM N 4ia 4 636 639 FTDBCI N 4ia 1 641 641 FTDNCI N 4ib 3 643 645 FTDPCI N 4ic 1 647 647 FTDMCI N 4id 3 649 651 FTDACI N 4ie 2 653 654 FTDBCJM N 4ja 4 656 659 FTDBCJ N 4ja 1 661 661 FTDNCJ N 4jb 3 663 665 FTDPCJ N 4jc 1 667 667 FTDMCJ N 4jd 3 669 671 FTDACJ N 4je 2 673 674 FTDBCKM N 4ka 4 676 679 FTDBCK N 4ka NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 7
Form A3F family history: affected family members CONTINUED 1 681 681 FTDNCK N 4kb 3 683 685 FTDPCK N 4kc 1 687 687 FTDMCK N 4kd 3 689 691 FTDACK N 4ke 2 693 694 FTDBCLM N 4la 4 696 699 FTDBCL N 4la 1 701 701 FTDNCL N 4lb 3 703 705 FTDPCL N 4lc 1 707 707 FTDMCL N 4ld 3 709 711 FTDACL N 4le 2 713 714 FTDBCMM N 4ma 4 716 719 FTDBCM N 4ma 1 721 721 FTDNCM N 4mb 3 723 725 FTDPCM N 4mc 1 727 727 FTDMCM N 4md 3 729 731 FTDACM N 4me NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 8
Form B3F Supplemental UPDRS 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 1 45 45 FTDLTFAS N A1 1 47 47 FTDLIMB N A2 1 49 49 FTDBULB N A3 1 51 51 FTDEYE N A4 1 53 53 FTDDYST N A5 1 55 55 FTDIDEO N A6 1 57 57 FTDALIEN N A7 1 59 59 FTDMYOCL N A8 1 61 61 FTDCORTS N A9 1 63 63 FTDGSEV N B1 60 65 124 FTDGSEVX C B1a 1 126 126 FTDGTYP N B2 60 128 187 FTDGTYPG C B2a 60 189 248 FTDGTYPX C B2b NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 9
Form B9F Clinical PPA and bvftd Features 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 1 45 45 FTDPPASL N 1 1 47 47 FTDPPAPO N 2 1 49 49 FTDPPAIW N 3 1 51 51 FTDPPASW N 4 1 53 53 FTDPPAPK N 5 1 55 55 FTDPPAGS N 6 1 57 57 FTDPPAEH N 7 1 59 59 FTDPPACS N 8 1 61 61 FTDPPASS N 9 1 63 63 FTDPPASR N 10 1 65 65 FTDPPASD N 11 1 67 67 FTDCPPA N 12 1 69 69 FTDCPPAS N 13 1 71 71 FTDBVCLN N 14 1 73 73 FTDBVDIS N 15 1 75 75 FTDBVAPA N 16 1 77 77 FTDBVLOS N 17 1 79 79 FTDBVRIT N 18 1 81 81 FTDBVHYP N 19 1 83 83 FTDBVNEU N 20 1 85 85 FTDBVIDL N 21 1 87 87 FTDBVFT N 22 1 89 89 FTDEMGPV N 23 NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 10
Form B9F clinical ppa and bvftd features CONTINUED 1 91 91 FTDEMGPY N 24 1 93 93 FTDEMGMN N 25 1 95 95 FTDPABVF N 26 NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 11
Form C1F Neuropsychological Battery Summary Scores 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 2 45 46 FTDBENTC N 1a 2 48 49 FTDVERFC N 2a 2 51 52 FTDVERFN N 2b 2 54 55 FTDVERNF N 2c 2 57 58 FTDVERLC N 2d 2 60 61 FTDVERLR N 2e 2 63 64 FTDVERLN N 2f 2 66 67 FTDVERTN N 2g 2 69 70 FTDVERTE N 2h 2 72 73 FTDVERTI N 2i 2 75 76 FTDWORRC N 3a 2 78 79 FTDWORRS N 3b 2 81 82 FTDWORRR N 3c 2 84 85 FTDWORIC N 3d 2 87 88 FTDWORIS N 3e 2 90 91 FTDWORIR N 3f 2 93 94 FTDWORIP N 3g 2 96 97 FTDBENTD N 4a 1 99 99 FTDBENRS N 4b 2 101 102 FTDSEMMT N 5a 2 104 105 FTDSEMAA N 6a 2 107 108 FTDSEMTA N 6b 2 110 111 FTDSEMSU N 6c NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 12
Form c1f neuropsychological battery summary scores CONTINUED 2 113 114 FTDANASW N 7a 2 116 117 FTDANAOW N 7b 2 119 120 FTDANATS N 7c 2 122 123 FTDSENAS N 8a 2 125 126 FTDSENOS N 8b 2 128 129 FTDSENSR N 8c 2 131 132 FTDSENPR N 8d 2 134 135 FTDNOUNC N 9a 2 137 138 FTDVERBC N 9b 5 140 144 FTDRATIO N 9c 2 146 147 FTDREAAS N 10a 2 149 150 FTDREAOS N 10b 2 152 153 FTDREASR N 10c 2 155 156 FTDREAPR N 10d NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 13
Form C2F Social Norms Questionnaire 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 2 45 46 FTDCPC2F N 0 1 48 48 FTDHAIRD N 1 1 50 50 FTDSPIT N 2 1 52 52 FTDNOSE N 3 1 54 54 FTDCOAGE N 4 1 56 56 FTDCRY N 5 1 58 58 FTDCUT N 6 1 60 60 FTDYTRIP N 7 1 62 62 FTDEATP N 8 1 64 64 FTDTELLA N 9 1 66 66 FTDOPIN N 10 1 68 68 FTDLAUGH N 11 1 70 70 FTDSHIRT N 12 1 72 72 FTDKEEPM N 13 1 74 74 FTDPICKN N 14 1 76 76 FTDOVER N 15 1 78 78 FTDEATR N 16 1 80 80 FTDHAIRL N 17 1 82 82 FTDSHIRW N 18 1 84 84 FTDMOVE N 19 1 86 86 FTDHUGS N 20 1 88 88 FTDLOUD N 21 1 90 90 FTDLOST N 22 NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 14
Form C2F social norms questionnaire CONTINUED 2 92 93 FTDSNTOT N 23 2 95 96 FTDSNTBS N 24 2 98 99 FTDSNTOS N 25 5 101 105 FTDSNRAT N 26 NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 15
Form C3F Social Behavior Observer Checklist 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 1 45 45 FTDSELF N 1 1 47 47 FTDBADLY N 1a 1 49 49 FTDDEPR N 1b 1 51 51 FTDEMOTD N 1c 1 53 53 FTDLSELF N 2 1 55 55 FTDDISR N 2a 1 57 57 FTDBELCH N 2b 1 59 59 FTDGIGG N 2c 1 61 61 FTDPRIV N 3 1 63 63 FTDNEGAT N 3a 1 65 65 FTDECOMM N 3b 1 67 67 FTDINAPJ N 3c 1 69 69 FTDFAILA N 4 1 71 71 FTDRESIS N 4a 1 73 73 FTDINTER N 4b 1 75 75 FTDVERBA N 4c 1 77 77 FTDPHYSI N 4d 1 79 79 FTDTOPIC N 4e 1 81 81 FTDPROTO N 4f 1 83 83 FTDPREO N 5 1 85 85 FTDFINI N 5a NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 16
Form C3F social behavior observer checklist CONTINUED 1 87 87 FTDACTED N 6 1 89 89 FTDABS N 6a 1 91 91 FTDFEEDB N 6b 1 93 93 FTDFRUST N 6c 1 95 95 FTDANXI N 7 1 97 97 FTDNERVO N 7a 1 99 99 FTDNDIAG N 7b 1 101 101 FTDSTIMB N 8 1 103 103 FTDSTIME N 8a 1 105 105 FTDOBJEC N 8b 1 107 107 FTDCIRCU N 8c 1 109 109 FTDPERSE N 9 1 111 111 FTDREPEA N 9a 1 113 113 FTDANECD N 9b 1 115 115 FTDDINIT N 10 1 117 117 FTDDELAY N 10a 1 119 119 FTDADDVE N 10b 1 121 121 FTDFLUCT N 11 1 123 123 FTDLOSTT N 11a 1 125 125 FTDREPRU N 11b 1 127 127 FTDTRAIN N 11c 1 129 129 FTDDISCL N 12 1 131 131 FTDSPONT N 12a 1 133 133 FTDSPONR N 12b 1 135 135 FTDSTOOD N 12c 1 137 137 FTDTOUCH N 12d 1 139 139 FTDDSOCI N 13 1 141 141 FTDEXAGG N 14 2 143 144 FTDSBTOT N 15 3 146 148 FTDSBCTO N 16 3 150 152 FTDLENGT N 17 NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 17
Form C4F Behavioral Inhibition Scale 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 1 45 45 FTDCPC4F N 0 1 47 47 FTDWORKU N 1 1 49 49 FTDMIST N 2 1 51 51 FTDCRIT N 3 1 53 53 FTDWORR N 4 1 55 55 FTDBAD N 5 1 57 57 FTDPOOR N 6 1 59 59 FTDFFEAR N 7 2 61 62 FTDBIST N 8 NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 18
Form C5F Interpersonal Reactivity Index 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 1 45 45 FTDCPC5F N 0 1 47 47 FTDINSEX N 0a 2 49 50 FTDINFMO N 0b 4 52 55 FTDINFYR N 0b 1 57 57 FTDINFRE N 0c 1 59 59 FTDFEEL N 1 1 61 61 FTDDIFF N 2 1 63 63 FTDSORR N 3 1 65 65 FTDSIDE N 4 1 67 67 FTDADVAN N 5 1 69 69 FTDIMAG N 6 1 71 71 FTDMISF N 7 1 73 73 FTDWASTE N 8 1 75 75 FTDPITY N 9 1 77 77 FTDQTOUC N 10 1 79 79 FTDSIDES N 11 1 81 81 FTDSOFTH N 12 1 83 83 FTDUPSET N 13 1 85 85 FTDCRITI N 14 2 87 88 FTDIRIEC N 15 2 90 91 FTDIRIPT N 16 NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 19
Form C6F Revised Self-monitoring Scale 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 1 45 45 FTDCPC6F N 0 1 47 47 FTDALTER N 1 1 49 49 FTDEMOT N 2 1 51 51 FTDACROS N 3 1 53 53 FTDCONV N 4 1 55 55 FTDINTUI N 5 1 57 57 FTDJOKE N 6 1 59 59 FTDIMAGP N 7 1 61 61 FTDINAPP N 8 1 63 63 FTDCHBEH N 9 1 65 65 FTDADBEH N 10 1 67 67 FTDLYING N 11 1 69 69 FTDGOODF N 12 1 71 71 FTDREGUL N 13 2 73 74 FTDSMSCR N 14 2 76 77 FTDSPSCR N 15 2 79 80 FTDRSMST N 16 NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 20
Form E2F Imaging Available 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 1 45 45 FTDSMRI N 1 2 47 48 FTDSMMO N 1a 2 50 51 FTDSMDY N 1a 4 53 56 FTDSMYR N 1a 1 58 58 FTDSMDIC N 1b 60 60 119 FTDSMDIS C 1b1 1 121 121 FTDSMADN N 1c 60 123 182 FTDSMADV C 1c1 1 184 184 FTDSMMAN N 1d 60 186 245 FTDSMMAO C 1d0 60 247 306 FTDSMMAM C 1d1 1 308 308 FTDSMFS N 1e 60 310 369 FTDSMFSO C 1e1 1 371 371 FTDSMQU N 1f 1 373 373 FTDFDGPT N 2 2 375 376 FTDFPMO N 2a 2 378 379 FTDFPDY N 2a 4 381 384 FTDFPYR N 2a 1 386 386 FTDFDDIC N 2b 60 388 447 FTDFDDID C 2b1 1 449 449 FTDFDADN N 2c 60 451 510 FTDFDADV C 2c1 1 512 512 FTDFDMAN N 2d NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 21
Form E2F IMAGING available CONTINUED 60 514 573 FTDFDMAO C 2d0 60 575 634 FTDFDMAM C 2d1 1 636 636 FTDFDQU N 2e 1 638 638 FTDAMYPT N 3 2 640 641 FTDAMMO N 3a 2 643 644 FTDAMDY N 3a 4 646 649 FTDAMYR N 3a 1 651 651 FTDAMDIC N 3b 60 653 712 FTDAMDID C 3b1 1 714 714 FTDAMLIG N 3c 60 716 775 FTDAMLIO C 3c1 1 777 777 FTDAMADN N 3d 60 779 838 FTDAMADV C 3d1 1 840 840 FTDAMMAN N 3e 60 842 901 FTDAMMAO C 3e0 60 903 962 FTDAMMAM C 3e1 1 964 964 FTDAMQU N 3f 1 966 966 FTDOTHER N 4 1 968 968 FTDOTDOP N 4a 1 970 970 FTDOTSER N 4b 1 972 972 FTDOTCHO N 4c 1 974 974 FTDOTANO N 4d 60 976 1035 FTDOTANS C 4d1 NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 22
Form E3F Imaging in Diagnosis 2 1 2 PACKET C 3 4 6 FORMID C 3 8 10 FORMVER N 2 12 13 ADCID N 10 15 24 PTID C 2 26 27 VISITMO N 2 29 30 VISITDAY N 4 32 35 VISITYR N 3 37 39 VISITNUM C 3 41 43 INITIALS C 1 45 45 FTDIDIAG N 1 1 47 47 FTDSMRIO N 2 1 49 49 FTDMRIFA N 2a 1 51 51 FTDMRIRF N 2a1 1 53 53 FTDMRILF N 2a2 1 55 55 FTDMRIRT N 2a3 1 57 57 FTDMRILT N 2a4 1 59 59 FTDMRIRM N 2a5 1 61 61 FTDMRILM N 2a6 1 63 63 FTDMRIRP N 2a7 1 65 65 FTDMRILP N 2a8 1 67 67 FTDMRIRB N 2a9 1 69 69 FTDMRILB N 2a10 1 71 71 FTDMRIOB N 2a11 60 73 132 FTDMRIOS C 2a11a 1 134 134 FTDFDGPE N 3 1 136 136 FTDFDGFH N 3a 1 138 138 FTDFDGRF N 3a1 1 140 140 FTDFDGLF N 3a2 1 142 142 FTDFDGRT N 3a3 1 144 144 FTDFDGLT N 3a4 1 146 146 FTDFDGRM N 3a5 1 148 148 FTDFDGLM N 3a6 1 150 150 FTDFDGRP N 3a7 NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 23
Form E3F IMAGING in diagnosis CONTINUED 1 152 152 FTDFDGLP N 3a8 1 154 154 FTDFDGRB N 3a9 1 156 156 FTDFDGLB N 3a10 1 158 158 FTDFDGOA N 3a11 60 160 219 FTDFDGOS C 3a11a 1 221 221 FTDAMYP N 4 1 223 223 FTDAMYVI N 4a 1 225 225 FTDAMYRF N 4a1 1 227 227 FTDAMYLF N 4a2 1 229 229 FTDAMYRT N 4a3 1 231 231 FTDAMYLT N 4a4 1 233 233 FTDAMYRM N 4a5 1 235 235 FTDAMYLM N 4a6 1 237 237 FTDAMYRP N 4a7 1 239 239 FTDAMYLP N 4a8 1 241 241 FTDAMYRB N 4a9 1 243 243 FTDAMYLB N 4a10 1 245 245 FTDAMYOA N 4a11 60 247 306 FTDAMYOS C 4a11a 1 308 308 FTDCBFSP N 5 1 310 310 FTDCBFVI N 5a 1 312 312 FTDCBFRF N 5a1 1 314 314 FTDCBFLF N 5a2 1 316 316 FTDCBFRT N 5a3 1 318 318 FTDCBFLT N 5a4 1 320 320 FTDCBFRM N 5a5 1 322 322 FTDCBFLM N 5a6 1 324 324 FTDCBFRP N 5a7 1 326 326 FTDCBFLP N 5a8 1 328 328 FTDCBFRB N 5a9 1 330 330 FTDCBFLB N 5a10 1 332 332 FTDCBFOA N 5a11 60 334 393 FTDCBFOS C 5a11a 1 395 395 FTDOTHI N 6 60 397 456 FTDOTHIS C 6a NACC UDS FTLD Data Template FVP (Version 2, January 2012) Page 24