Cash Receipt Form

ATTACHMENT D

Cash Receipt Form

CASH RECEIPT FORM

CHATS Cash Receipt Form – Parent/Guardian

RTI International would like to thank you for your participation in Children’s Health after the Storms. As a token of our appreciation for your participation in each aspect of this research study, we would like to present you with the following:

• $40.00 for Interview and Environmental Equipment Set-Up (Session 1)

• $35.00 for Interview and Environmental Equipment Retrieval (Session 2)

$___________ Total Cash Amount

 Accepted Cash Amount

 Declined Cash Amount

Name of Respondent (Print):___________________________________

Signature of Respondent:______________________________________

Signature of Field Interviewer:

Case ID: Date: ___ / ____ / ____

Disposition: Top White to Respondent, Yellow to FS, Pink to FI

CHATS Cash Receipt Form – Child (8 – 15)

RTI International would like to thank you for your participation in Children’s Health after the Storms. As a token of our appreciation for your participation in each aspect of this research study, we would like to present you with the following:

• $15.00 for Child Health Assessment (Session 2)

• $20.00 for Blood Sample (Session 2)

• $30.00 for Wearing Personal Exposure Measuring Device (Session 2)

$___________ Total Cash Amount

 Accepted Cash Amount

 Declined Cash Amount

Name of Respondent (Print):___________________________________

Signature of Parent:______________________________________ ____

Signature of Field Interviewer:

Case ID: Date: ___ / ____ / ____

Disposition: Top White to Respondent, Yellow to FS, Pink to FI

Cash Receipt Form D-2