Form 7 Incentive distribution log for focus group participants

OMB No. 0925-XXXX

Exp. Date: XX/XX/20XX

Attachment 14: Incentive distribution log for focus group participants

Burden Disclosure: Public reporting burden for this collection of information is estimated to average 2 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA# 0925-XXXX. Do not return the completed form to this address.

Date of Focus Group: ___________________ Location: ____________________________________________________________

Name (Please Print)	Incentive $Amount Received	Participant Signature	Date
	$_____ N/A
	$_____ N/A
	$_____ N/A
	$_____ N/A
	$_____ N/A
	$_____ N/A
	$_____ N/A