Minnesota Participation Record

Attachment 5g (MN 7.2) Participation Record FORM APPROVED

5.8 reading level without burden statement OMB No. 0923-XXXX

Expiration Date: MM/DD/ YYYY

Fond du Lac

^{Human Services}

NAME TBD

Fond du Lac Community Biomonitoring Study

Participation Record

By signing below, you state that you received the gift cards listed. Your signature will only be used to show you received the gift cards. Your signature will not be used for any other reason.

First Card

I received a $25 gift card as thanks for reviewing the consent form.

_____________________________ ___________________ __________

Signature Date Staff Initials

Second Card

I received a $25 gift card as thanks for doing the clinic part of the study.

_____________________________ ___________________ __________

Signature Date Staff Initials

Third Card

I received a $25 gift card as thanks for completing the interview.

_____________________________ ___________________ __________

Signature Date Staff Initials

Study ID Total Gift Card Amount: 25 50 75

Public reporting burden of this collection of information is estimated to average 3 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).

Appendix 7.2. page 1