Program Director/Principal Investigator (Last, First, Middle): |
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Inclusion Enrollment Report |
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This report format should NOT be used for data collection from study participants. |
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Study Title: |
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Total Enrollment: |
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Protocol Number: |
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Grant Number: |
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PART A. TOTAL
ENROLLMENT REPORT: Number of Subjects Enrolled to Date
(Cumulative) |
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Ethnic Category |
Sex/Gender |
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Females |
Males |
Unknown or Not Reported |
Total |
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Hispanic or Latino |
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** |
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Not Hispanic or Latino |
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Unknown (individuals not reporting ethnicity) |
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Ethnic Category: Total of All Subjects* |
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* |
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Racial Categories |
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American Indian/Alaska Native |
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Asian |
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Native Hawaiian or Other Pacific Islander |
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Black or African American |
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White |
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More Than One Race |
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Unknown or Not Reported |
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Racial Categories: Total of All Subjects* |
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* |
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PART B. HISPANIC ENROLLMENT REPORT: Number of Hispanics or Latinos Enrolled to Date (Cumulative) |
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Racial Categories |
Females |
Males |
Unknown or Not Reported |
Total |
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American Indian or Alaska Native |
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Asian |
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Native Hawaiian or Other Pacific Islander |
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Black or African American |
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White |
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More Than One Race |
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Unknown or Not Reported |
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Racial Categories: Total of Hispanics or Latinos** |
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** |
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* These totals must agree. ** These totals must agree. |
PHS 398/2590 (Rev. 09/07) Page Inclusion Enrollment Report Format Page
File Type | application/msword |
File Title | PHS 398 (Rev. 9/07), Inclusion Enrollment Report |
Subject | DHHS, Public Health Service Grant Application |
Author | Office of Extramural Programs |
Last Modified By | curriem |
File Modified | 2007-09-14 |
File Created | 2007-09-14 |