Referral Coupons

FORM APPROVED

OMB NO.: 0920-0840

EXPIRATION DATE: 2/28/2016

COUPON NUMBER: __________

Formative Research to Assess Injection Behaviors Among Young Persons who Inject Drugs in Rural and Suburban Settings

NORC at the University of Chicago

You have been given this coupon by a friend or acquaintance to invite you to be a part of a study of injection drug use and Hepatitis C testing. Please bring this coupon OR the coupon number to the AIDS Resource Center of Wisconsin (ARCW) to participate in this study.

AIDS Resource Center of Wisconsin

1212 57th Street

Kenosha, WI

301-634-9424

Your participation in this study is completely voluntary, and all information we obtain about you is completely confidential. We will give you a $15 token of appreciation for completing a survey and providing a blood spot for the HCV test and to thank you for your help on the study.

This coupon/coupon number expires: ___/___/___.

Formative Research to Assess Injection Behaviors Among Young Persons who Inject Drugs in Rural and Suburban Settings

NORC at the University of Chicago

Come with this coupon OR coupon number to participate in this study to receive:

• A $15 token of appreciation for completing a survey and a HCV test;

• A chance to refer up to 3 peers for $10/peer; and

• Free HCV testing

To be eligible for this study, you must:

• Be between the ages of 18 and 29

• Have injecting drugs not prescribed by a doctor in the past year(12 months)

• Be able to complete a survey in English

• Have a photo ID (to confirm name and year of birth)

Formative Research to Assess Injection Behaviors Among Young Persons who Inject Drugs in Rural and Suburban Settings

NORC at the University of Chicago

You have been given this coupon by a friend or acquaintance to invite you to be a part of a study of injection drug use and Hepatitis C testing. Please bring this coupon OR the coupon number to Bethany Place to participate in this study.

Bethany Place

821 W a St # 4  

Belleville, IL 62220

301-634-9424

Your participation in this study is completely voluntary, and all information we obtain about you is completely confidential. We will give you a $15 token of appreciation to compensate you for completing a survey and providing a blood spot for a HCV test and to thank you for your help on the study.

This coupon/coupon number expires: ___/___/___.

Formative Research to Assess Injection Behaviors Among Young Persons who Inject Drugs in Rural and Suburban Settings

NORC at the University of Chicago

Come with this coupon OR coupon number to participate in this study to receive:

• A $15 token of appreciation for completing a survey and a HCV test;

• A chance to refer up to 3 peers for $10/peer; and

• Free HCV testing

To be eligible for this study, you must:

• Be between the ages of 18 and 29

• Have injecting drugs not prescribed by a doctor in the past year(12 months)

• Be able to complete a survey in English

• Have a photo ID (to confirm name and year of birth)