QDRL-OMB Attachment F

Attachment F

Cash Payment Receipt form

Centers for Disease Control and Prevention

National Center for Health Statistics

Questionnaire Design Research Laboratory (QDRL)

3311 Toledo Road, Hyattsville, MD 20782

Cash Payment Receipt

I ______________________________________________ have received $[fill amount] (cash)

Print Name (First Name, Last Name)

for participating in a 60-minute/90-minute One-on-One Interview/Focus Group evaluating survey questions about [fill topic].

_____________________________________________

Signature (First name, Last Name)

_____________________________________________

Street address

_____________________________________________

City, State, Zip code

________________________

Date (mm/dd/yy)

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For Office Use Only

Project: [fill project name]