10 form

Name of Applicant (Last, first, middle):

     

Inclusion Enrollment Report

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

Study Title:

     

Total Enrollment:

     

Protocol Number:

     

Grant Number:

     

PART A. TOTAL ENROLLMENT REPORT: Number of Subjects Enrolled to Date (Cumulative) by Ethnicity and Race

Ethnic Category

Sex/Gender

Females

Males

Unknown or Not Reported

Total

Hispanic or Latino

     

     

     

     

**

Not Hispanic or Latino

     

     

     

     

Unknown (individuals not reporting ethnicity)

     

     

     

     

Ethnic Category: Total of All Subjects*

     

     

     

     

*

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 Subjects*

     

     

     

     

*

PART B. HISPANIC ENROLLMENT REPORT: Number of Hispanics or Latinos Enrolled to Date (Cumulative)

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**

     

     

     

     

**

* These totals must agree. ** These totals must agree.

PHS 416-1/416-9 (Rev. 10/08) Page     Inclusion Enrollment Report Format Page