10-0455a

Clinical Trial Inclusion/Enrollment Report

Agency
VA
Revision
November 2008
Fillable fields
63
Pages
1
Official source
VA form page
Checked
October 20, 2026
Fill 10-0455a online
Page 1 of form 10-0455a

VA Form 10-0455a: Clinical Trial Inclusion/Enrollment Report

VA Form 10-0455a is the U.S. Department of Veterans Affairs Clinical Trial Inclusion/Enrollment Report. It is a VA research form. Its upper section is titled Clinical Trial Annual Progress Report and identifies the project, the reporting period, the VA medical center and the principal investigator. VA's form page lists it under VHA.

The form is one page. After the project details it asks for the trial's recruiting status, the total projected enrollment and the total enrollment to date, then Part A, a table of the number of subjects enrolled to date (cumulative) by ethnicity and race, split by females, males and unknown or not reported. It ends with the name and title of the person completing it and a Submit by E-mail button. You can fill out the PDF free in your browser on this page and download the result without an account.

Top of page 1 of VA Form 10-0455a: Clinical Trial Inclusion/Enrollment Report, as printed by VA

What's on VA Form 10-0455a

Progress report summary

Project ID, the period covered by the report from and through, the VA medical center, the principal investigator and the title of the project.

Recruiting status

One box to check: Not Yet Recruiting, Recruiting, No Longer Recruiting or Completed.

Enrollment totals

The total projected enrollment and the total enrollment to date.

Part A: ethnic categories

Hispanic or Latino, Not Hispanic or Latino and Unknown, with columns for females, males, unknown or not reported and a total, plus a total of all subjects.

Part A: racial categories

American Indian/Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, Black or African American, White, More than One Race and Unknown or Not Reported, with a total of all subjects.

Completer and submission

The name and title of the completer, the Submit by E-mail button and the fallback address [email protected].

How to complete VA Form 10-0455a

  1. 1

    Enter the project details

    Fill in the project ID, the from and through dates of the reporting period, the VA medical center, the principal investigator and the project title.

  2. 2

    Check one status box

    The form says to check only one box for the trial's recruiting status.

  3. 3

    Enter the enrollment numbers

    Give the total projected enrollment and the total enrollment to date, then the cumulative counts in Part A by ethnicity and race, with totals.

  4. 4

    Add the completer

    Enter the name and title of the person completing the report.

  5. 5

    Submit it by email

    Use the Submit by E-mail button. If it does not work, the form says it can be sent to [email protected].

Why fill Form 10-0455a on indox

You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.

  • Fill the form right in your browser, no software to install
  • Free to fill and free to download, with no account
  • The official blank straight from the VA, not a copy someone retyped
  • Works on a phone, tablet or computer

Where to send it

By email

The form has a Submit by E-mail button. If the button does not work, the form says it can be sent to [email protected].

No mailing address

The form prints no mailing address or fax number.

Edition

The current edition is dated NOV 2008 and has one page.

Related forms

Who uses VA Form 10-0455a?

  • VA clinical trial teams

    The report identifies the VA medical center, the principal investigator, the project ID and the title of the project for the period covered.

  • The person completing the report

    The bottom of the form records the name and title of the completer.

  • The VA office receiving it

    The form has a Submit by E-mail button and says that if the button does not work, the form can be sent to [email protected].

  • Study subjects are counted, not named

    Part A asks only for numbers of subjects by ethnic and racial category and by sex or gender. The form has no fields for subjects' names.

The form names these people and offices.

Official sources and the blank

Do it all with indox

View all 94 tools

Questions about Form 10-0455a

What is VA Form 10-0455a?

It is the Clinical Trial Inclusion/Enrollment Report. Its upper section is titled Clinical Trial Annual Progress Report and reports enrollment in a VA clinical trial by ethnicity, race and sex or gender.

Are the Part A numbers cumulative?

Yes. Part A asks for the number of subjects enrolled to date (cumulative) by ethnicity and race.

How many status boxes can be checked?

One. The form says to check only one box: Not Yet Recruiting, Recruiting, No Longer Recruiting or Completed.

Where is VA Form 10-0455a sent?

The form has a Submit by E-mail button and says that if it does not work, the form can be sent to [email protected].

Does the report list study subjects by name?

No. Part A asks for counts of subjects by ethnic and racial category and by sex or gender, not names.