Form 2 PHS_Inclusion-Enrollment-Form

Public Burden Statement: 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. The OMB control number for this project is 0906-XXXX. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time
for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.

OMB No. 0906-XXXX
Exp. XX/XX/20XX

Maternal and Child Health Bureau Inclusion Enrollment Form
This report format should NOT be used for collecting data from study participants.

*Study Title
(must be
unique):
If study is not delayed onset, the following selections are required:

Using an Existing Dataset or
Resources
Enrollment Location (state)

Yes

No

Clinical Trial

Yes

No

Comments:

Ethnic Categories
Racial Categories

Not Hispanic or Latino
Female

Hispanic or Latino

Unknown/
Not
Reported

Male

Female

Unknown/
Not
Reported

Male

Total

Unknown/Not Reported Ethnicity
Female

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

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