Form 1 Form

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

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:
Number of Trainees from Disadvantaged Backgrounds:
(*) (**) These totals must agree.

0925-0002 (Rev. 08/2024 Approved through 01/31/2026)

Page

Trainee Diversity Report Format Page

Public reporting burden for this collection of information is estimated to average 15/60 hours per response,
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data needed, and completing and reviewing the collection of information. An agency may not conduct or
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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
return the completed form to this address.