Demographics
DemographicsSTUDY NAMESite Number: Pt_ID: Visit Date: / / .d dm m myyyyVisit Type: Screening BaselineGender: Female MaleDate of Birth: / / .ddmmmyyyyRace (“X” ONLY one with which you MOST CLOSELY identify):American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMore than one raceUnknown or not reportedEthnicity (“X” ONLY one with which you MOST CLOSELY identify):Hispanic or LatinoNot Hispanic or LatinoUnknown or not reportedDate Informed Consent Signed: / / .ddmmmyyyyInvestigator Signature: / / ..ddmmmyyyy ................
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