QDRL-OMB Attachment F Cash Payment Receipt

QDRL-OMB Attachment F Cash Payment Receipt.doc

NCHS Questionnaire Design Research Laboratory

QDRL-OMB Attachment F Cash Payment Receipt

OMB: 0920-0222

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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 topics].




_____________________________________________

Signature (First name, Last Name)




________________________

Date (mm/dd/yy)














------------------------------------------------------------------------------------------------------------

For Office Use Only

Project: [fill project name]


File Typeapplication/msword
File TitleCenters for Disease Control and Prevention
AuthorKaren Roberta Whitaker
Last Modified ByCDC User
File Modified2012-02-13
File Created2012-01-06

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