INCLUSION TABLE 
This report format should NOT be used for data collection from study participants. 
Principal Investigator/Project Director _____________________________________________________ (Last, First, Middle)  
Grant Number (if known): ____________________________  
STUDY TITLE: _______________________________________________________________________________  
Total Enrollment: ________________________ Protocol Number: ____________________________ 
American Indian or 
Alaskan Native 
Asian or Pacific Islander 
Black, not of Hispanic 
Origin 
Hispanic 
White, not of Hispanic 
Origin 
Other or Unknown 
Total 
Female 
Male 
Unknown 
Total