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- Section 1 —Montreal Cognitive Assessment (MoCA)
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(Not corrected for education or visual/hearing impairment)
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(Enter 88 if any of the following MoCA items were not administered: 1g –1l, 1n–1t, 1w–1bb)
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- Section 2 —Administration of the remainder of the battery
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- Section 3 —Craft Story 21 Recall (Immediate)
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(If test not completed, enter reason code, 95–98, and SKIP TO QUESTION 4a.)
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- Section 4 —Benson Complex Figure Copy
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(If test not completed, enter reason code, 95–98)
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- Section 5 — Number Span Test: Forward
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(If test not completed, enter reason code, 95–98, and SKIP TO QUESTION 6a.)
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- Section 6 — Number Span Test: Backward
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(If test not completed, enter reason code, 95–98, and SKIP TO QUESTION 7a.)
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- Section 7 — Category Fluency
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(If test not completed, enter reason code, 95–98)
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(If test not completed, enter reason code, 95–98)
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- Section 8 — Trail Making Test
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(If test not completed, enter reason code, 995–998, and SKIP TO QUESTION 8b.).
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(If test not completed, enter reason code, 995–998, and SKIP TO QUESTION 9a.).
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- Section 9 — Benson Complex Figure Recall
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(If test not completed, enter reason code, 95–98, and SKIP TO QUESTION 10a.
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- Section 10 — Craft Story 21 Recall (Delayed)
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(If test not completed, enter reason code, 95–98, and SKIP TO QUESTION 11a.)
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- Section 11 — Verbal Fluency: Phonemic Test
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(If test not completed, enter reason code, 95–98, and SKIP TO QUESTION 11d.)
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(If test not completed, enter reason code, 95–98, and SKIP TO QUESTION 12a.)
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- Section 12 — Rey Auditory Verbal Learning (Immediate)
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Total number of words correctly recalled and number of intrusions
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- Trial |
- Total recall |
- # of intrusions |
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- Trial 1 |
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- (If test was not completed, enter reason code, 95-98. SKIP TO QUESTION 16a.)
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- Trial 2 |
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- Trial 3 |
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- Trial 4 |
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- Trial 5 |
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- List B |
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- Trial 6 |
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- Section 13 — Rey Auditory Verbal Learning (Delayed Recall and Recognition)
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(If test not completed, enter reason code, 95-98, and SKIP TO QUESTION 16a.)
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- Section 14 — CERAD Verbal Learning (Immediate)
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- J4 Word List Memory Task: Total number of words correctly recalled and number of intrusions
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- Trial |
- Total recall |
- Can't read |
- # of intrusions |
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- Trial 1 |
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- (If test was not completed, enter reason code, 95-98. SKIP TO QUESTION 16a.)
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- Trial 2 |
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- Trial 3 |
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- Section 15 — CERAD Verbal Learning (Delayed Recall and Recognition)
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(If test not completed, enter reason code, 95-98, and SKIP TO QUESTION 16a.)
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(If test not completed, enter reason code, 95-98, and SKIP TO QUESTION 16a.)
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- Section 16 — Multilingual Naming Test (MINT)
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(If test not completed, enter reason code, 95–98, and SKIP TO QUESTION 17a)
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- Section 17 — Overall appraisal
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- Section 18 — Validity of participant’s response
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- Please record your impression of whether hearing or other factors significantly influenced test results. It can be difficult to judge, but
- it is helpful in adjudication and data analysis to know that such an influence may have been present.
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- What makes this participant’s responses less valid?
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- (Check all that apply)
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- @Html.CheckBox("C2.RESPHEAR", Model.C2.RESPHEAR, new { @class = "h-4 w-4 rounded border-gray-300 text-indigo-600 focus:ring-indigo-600 disabled:bg-slate-50 disabled:text-slate-500 disabled:border-slate-200 disabled:shadow-none" })
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- @Html.CheckBox("C2.RESPDIST", Model.C2.RESPDIST, new { @class = "h-4 w-4 rounded border-gray-300 text-indigo-600 focus:ring-indigo-600 disabled:bg-slate-50 disabled:text-slate-500 disabled:border-slate-200 disabled:shadow-none" })
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- @Html.CheckBox("C2.RESPINTR", Model.C2.RESPINTR, new { @class = "h-4 w-4 rounded border-gray-300 text-indigo-600 focus:ring-indigo-600 disabled:bg-slate-50 disabled:text-slate-500 disabled:border-slate-200 disabled:shadow-none" })
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- @Html.CheckBox("C2.RESPDISN", Model.C2.RESPDISN, new { @class = "h-4 w-4 rounded border-gray-300 text-indigo-600 focus:ring-indigo-600 disabled:bg-slate-50 disabled:text-slate-500 disabled:border-slate-200 disabled:shadow-none" })
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- @Html.CheckBox("C2.RESPFATG", Model.C2.RESPFATG, new { @class = "h-4 w-4 rounded border-gray-300 text-indigo-600 focus:ring-indigo-600 disabled:bg-slate-50 disabled:text-slate-500 disabled:border-slate-200 disabled:shadow-none" })
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- @Html.CheckBox("C2.RESPEMOT", Model.C2.RESPEMOT, new { @class = "h-4 w-4 rounded border-gray-300 text-indigo-600 focus:ring-indigo-600 disabled:bg-slate-50 disabled:text-slate-500 disabled:border-slate-200 disabled:shadow-none" })
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Info
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+ Info Alert! Modality selection will determine whether the C2 or C2T form is displayed.
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+ @if (Model.Visit != null && (Model.C2.RMMODE == RemoteModality.Telephone))
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- @Html.CheckBox("C2.RESPASST", Model.C2.RESPASST, new { @class = "h-4 w-4 rounded border-gray-300 text-indigo-600 focus:ring-indigo-600 disabled:bg-slate-50 disabled:text-slate-500 disabled:border-slate-200 disabled:shadow-none" })
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+ {
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+ }
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+ else if (Model.Visit != null && (Model.C2.MODE == FormMode.InPerson) || (Model.C2.RMMODE == RemoteModality.Video))
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- @Html.CheckBox("C2.RESPOTH", Model.C2.RESPOTH, new { @class = "h-4 w-4 rounded border-gray-300 text-indigo-600 focus:ring-indigo-600 disabled:bg-slate-50 disabled:text-slate-500 disabled:border-slate-200 disabled:shadow-none", data_affects = "true", data_affects_toggle_targets = "[ \"C2.RESPOTHX\"]" })
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- }
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