Parents-Minor Surveys

Appendix D5

Focus Group

Participant Incentive Receipt Form:

English

OMB#: 0584-XXXX

Expiration Date: xx/xx/20xx

Public reporting burden for this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx). Do not return the completed form to this address.

FOCUS GROUP PARTICIPANT INCENTIVE RECEIPT FORM

I have received $75 in cash for participating in a focus group discussion about the Healthy Incentives Pilot study.

_________________________________________ ____________________

Signature Date