Incentive Receipt

CASH INCENTIVE RECEIPT

RTI PROJECT # ________--- __________ CASE ID #________________

To show our appreciation for the time you spent answering our questions for this important study we are authorized to pay you a cash incentive of $50. Since maintaining the confidentiality of your information is important to us, we ask that you not enter your full name on this form. However, the interviewer must sign and date this form to certify you have received (or declined) the cash payment.

 Accepted $50.00 Cash Incentive

 Declined $50.00 Cash Incentive

Recipient's Initials (PLEASE DO NOT SIGN YOUR NAME) _____________ Date: ___/ ___/ ___

Interviewer's Signature: ______________________________________ FI ID # ___________

Disposition: Original to RTI with case materials, yellow to supervisor, gold copy to respondent.

CASH INCENTIVE RECEIPT

RTI PROJECT # ________--- __________ CASE ID #________________

To show our appreciation for the time you spent answering our questions for this important study we are authorized to pay you a cash incentive of $50. Since maintaining the confidentiality of your information is important to us, we ask that you not enter your full name on this form. However, the interviewer must sign and date this form to certify you have received (or declined) the cash payment.

 Accepted $50.00 Cash Incentive

 Declined $50.00 Cash Incentive

Recipient's Initials (PLEASE DO NOT SIGN YOUR NAME) _____________ Date: ___/ ___/ ___

Interviewer's Signature: ______________________________________ FI ID # ___________

Disposition: Original to RTI with case materials, yellow to supervisor, gold copy to respondent.