Intercept Interview Receipt Form

Form Approved

OMB No. 0920-0572

Expiration Date 03/31/2018

Submission under

0920-0572 Health Message Testing System

Attachment 20: Intercept Interview Receipt Form

Attachment 20 Intercept Interview Receipt Form

High Impact Prevention Message Testing

I acknowledge receiving $10 as a token of appreciation for participating in an interview for the [INSERT TITLE] project conducted by RTI.

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Participant Initials Date

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Interviewer Signature Date