Va Form 10-0455a - Clinical Trial Inclusion/ Enrollment Report

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CLINICAL TRIAL INCLUSION/
ENROLLMENT REPORT
CLINICAL TRIAL ANNUAL PROGRESS REPORT
PERIOD COVERED BY THIS REPORT
PROJECT ID
PROGRESS REPORT
SUMMARY
FROM
THROUGH
VA MEDICAL CENTER
PRINCIPAL INVESTIGATOR
TITLE OF PROJECT
Status (PLEASE CHECK ONLY ONE BOX):
Not Yet Recruiting
Recruiting
No Longer Recruiting
Completed
Total Projected Enrollment:
Total Enrollment to Date:
PART A: TOTAL ENROLLMENT REPORT: Number of Subjects Enrolled to Date (Cumulative) by Ethnicity and Race
Sex/Gender
Unknown or Not
Ethnic Category
Females
Males
Total
Reported
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
Name of Completer:
Title of Completer:
If the e-mail button does not work you can send the form to :
VA FORM
10-0455a
Submit by E-mail
NOV 2008
CLIN-Review@va.gov.

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