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pdfPublic 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
Report 1 of 1
| File Type | application/pdf |
| File Title | PHS 398 Cumulative Inclusion Enrollment Report |
| Author | Administrator |
| File Modified | 2019-12-30 |
| File Created | 2019-12-19 |