Form 21 Trainee Diversity Report

Public reporting burden for this collection of information is estimated to 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0002). Do not send reports to this address.

Form Approved Through 08/31/2015

OMB No. 0925-0002

Program Director/Principal Investigator (Last, First, Middle):

     

Trainee Diversity Report

This report format should NOT be used for data collection from trainees.

Training Grant Title:

     

Total Number of Appointed:

     

Grant Number:

     

PART A. TOTAL TRAINEE APPOINTMENTS REPORT: Number of Trainees Appointed by Ethnicity and Race

Ethnic Category

Females

Males

Sex/Gender Unknown or Not Reported

Total

Hispanic or Latino

     

     

     

     

**

Not Hispanic or Latino

     

     

     

     

Unknown (individuals not reporting ethnicity)

     

     

     

     

Ethnic Category: Total of All Trainees*

     

     

     

     

*

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 Trainees*

     

     

     

     

*

PART B. HISPANIC TRAINEE APPOINTMENTS REPORT: Number of Hispanics or Latinos Appointed

Racial Categories

Females

Males

Sex/Gender 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**

     

     

     

     

**

PART C. TRAINEES WITH DISABILITIES OR FROM DISADVANTAGED BACKGROUNDS

Number of Trainees with Disabilities (as described in the Americans with Disabilities Act):

     

Number of Trainees from Disadvantaged Backgrounds (applies only to undergraduate and high school students:

     

(*) (**) These totals must agree.

0925-0002 (Rev. 06/15) Page     Trainee Diversity Report Format Page