15 form

		Name of Applicant (Last, first, middle):	     
Targeted/Planned Enrollment Table This report format should NOT be used for data collection from study participants.
Study Title:	     
Total Planned Enrollment:		     
TARGETED/PLANNED ENROLLMENT: Number of Subjects
Ethnic Category				Sex/Gender
				Females	Males	Total
Hispanic or Latino				     	     	     
Not Hispanic or Latino				     	     	     
Ethnic Category: Total of All Subjects *				     	     	     
Racial Categories
American Indian/Alaska Native				     	     	     
Asian				     	     	     
Native Hawaiian or Other Pacific Islander				     	     	     
Black or African American				     	     	     
White				     	     	     
Racial Categories: Total of All Subjects *				     	     	     

* The “Ethnic Category: Total of All Subjects” must be equal to the “Racial Categories: Total of All Subjects.”

PHS 416-1/416-9 (Rev. 10/08) Page     Targeted/Planned Enrollment Table Format Page