17 PHS Human Subjects and Clinical Trial Information - Incl

PHS Applications and Pre-award Related Reporting (OD)

Attachment 5F PHS Human Subjects and Clinical Trial Information - Inclusion Enrollment Report

398/424 PHS Human Subjects and Clinical Trial Information (includes inclusion enrollment report)

OMB: 0925-0001

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Inclusion Enrollment Report
 1. * Using an Existing Dataset or Resource

Yes

No

 2. * Enrollment Location Type:

Domestic

Foreign

 3.   Enrollment Country(ies):

UNITED STATES OF AMERICA

 4. * Enrollment Location:

 Planned:
Ethnic Categories
Racial Categories

Not Hispanic or Latino
Female

Not Hispanic or Latino

Male

Female

Not Hispanic or Latino

Male

Female

Total

Male

American Indian/Alaska
Native

0

0

0

0

0

0

0

Asian

0

0

0

0

0

0

0

Native Hawaiian or Other
Pacific Islander

0

0

0

0

0

0

0

Black or African
American

0

0

0

0

0

0

0

White

0

0

0

0

0

0

0

More than One Race

0

0

0

0

0

0

0

Total

0

0

0

0

0

0

0

 Cumulative (Actual):

Ethnic Categories
Racial Categories

Not Hispanic or Latino
Female

Not Hispanic or Latino

Unknown/
Not
Reported

Male

Female

Not Hispanic or Latino

Unknown/
Not
Reported

Male

Female

Total

Unknown/
Not
Reported

Male

American
Indian/Alaska Native

0

0

0

0

0

0

0

0

0

0

Asian

0

0

0

0

0

0

0

0

0

0

Native Hawaiian or
Other Pacific Islander

0

0

0

0

0

0

0

0

0

0

Black or African
American

0

0

0

0

0

0

0

0

0

0

White

0

0

0

0

0

0

0

0

0

0

More than One Race

0

0

0

0

0

0

0

0

0

0

Unknown or Not
Reported

0

0

0

0

0

0

0

0

0

0

Total

0

0

0

0

0

0

0

0

0

0

Participant level data file (CSV):

http://k2a9a1.axshare.com/ierform.html#rppr=Y&CSUM=1

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