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Name of Applicant (Last, first, middle): |
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This report format should NOT be used for data collection from study participants.
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.
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PHS 416-1/416-9 (Rev. 10/08) Page Inclusion Enrollment Report Format Page
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |