16 Trainee

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

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 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.

PHS 2590 (Rev. 09/07) Page     Trainee Diversity Report Format Page