Inclusion Enrollment Report |
|||||||||||||
This report format should NOT be used for data collection from study participants. |
|||||||||||||
Study Title: |
|
||||||||||||
Total Enrollment: |
|
Protocol Number: |
|
||||||||||
Grant Number: |
|
|
|||||||||||
|
|||||||||||||
PART A. TOTAL
ENROLLMENT REPORT: Number of Subjects Enrolled to Date
(Cumulative) |
|||||||||||||
Ethnic Category |
Sex/Gender |
||||||||||||
Females |
Males |
Unknown or Not Reported |
Total |
||||||||||
Hispanic or Latino |
|
|
|
|
** |
||||||||
Not Hispanic or Latino |
|
|
|
|
|
||||||||
Unknown (individuals not reporting ethnicity) |
|
|
|
|
|
||||||||
Ethnic Category: Total of All Subjects* |
|
|
|
|
* |
||||||||
Racial Categories |
|
||||||||||||
American Indian/Alaska Native |
|
|
|
|
|
||||||||
Asian |
|
|
|
|
|
||||||||
Native Hawaiian or Other Pacific Islander |
|
|
|
|
|
||||||||
Black or African American |
|
|
|
|
|
||||||||
White |
|
|
|
|
|
||||||||
More Than One Race |
|
|
|
|
|
||||||||
Unknown or Not Reported |
|
|
|
|
|
||||||||
Racial Categories: Total of All Subjects* |
|
|
|
|
* |
||||||||
|
|||||||||||||
PART B. HISPANIC ENROLLMENT REPORT: Number of Hispanics or Latinos Enrolled to Date (Cumulative) |
|||||||||||||
Racial Categories |
Females |
Males |
Unknown or Not Reported |
Total |
|||||||||
American Indian or Alaska Native |
|
|
|
|
|
||||||||
Asian |
|
|
|
|
|
||||||||
Native Hawaiian or Other Pacific Islander |
|
|
|
|
|
||||||||
Black or African American |
|
|
|
|
|
||||||||
White |
|
|
|
|
|
||||||||
More Than One Race |
|
|
|
|
|
||||||||
Unknown or Not Reported |
|
|
|
|
|
||||||||
Racial Categories: Total of Hispanics or Latinos** |
|
|
|
|
** |
||||||||
* These totals must agree. ** These totals must agree. |
File Type | application/msword |
File Title | PHS 398 (Rev. 9/04), Inclusion Enrollment Report |
Subject | DHHS, Public Health Service Grant Application |
Author | Office of Extramural Programs |
Last Modified By | Perryman |
File Modified | 2013-03-13 |
File Created | 2013-03-13 |