Fillable Printable VA Form 10-0455A
Fillable Printable VA Form 10-0455A
VA Form 10-0455A
PERIOD COVERED BY THIS REPORT
CLINICAL TRIAL ANNUAL PROGRESS REPORT
TITLE OF PROJECT
PROGRESS REPORT
SUMMARY
THROUGH
FROM
PROJECT ID
VA MEDICAL CENTER PRINCIPAL INVESTIGATOR
Status (PLEASE CHECK ONLY ONE BOX):
Not Yet Recruiting
No Longer Recruiting
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
Ethnic Category
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
Name of Completer: Title of Completer:
CLINICAL TRIAL INCLUSION/
ENROLLMENT REPORT
VA FORM
10-0455a
NOV 2008
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