Multicultural youth aged 13-17 in the select media markets recruiting through social media and online panels - Pre-test online screener

OMB No. xxxx-xxxx
Exp. Date xx/xx/xxxx

Interview Incentive Receipt

U.S. Food and Drug Administration

and

RTI International

Thank you for participating in the Evaluation of the Fresh Empire Campaign on Tobacco.

In appreciation of your participation in this important study, you are eligible to receive $25 in cash.

Since maintaining the confidentiality of your information is important to us, your name will not be entered on this form. However, the interviewer must sign and date this form to certify you received (or declined) the cash incentive.

___________________________________ _________ __ __ __ __ __ __ __ __ __ __ - __

Interviewer Date Case ID

□ Accepted Cash Incentive □ Declined Cash Incentive