Incentive Receipt Form

Attachment M:

ODPHP Physical Activity Guidelines, 2^nd Edition

Incentive Receipt Form for Parent Focus Groups

OMB Control Number: 0990-0281

December 21, 2017

Submitted to:

Sherrette Funn

Office of the Chief Information Officer

U.S. Department of Health and Human Services

Submitted by:

Frances Bevington

Strategic Communication and Public Affairs Advisor

Office of Disease Prevention and Health Promotion

U.S. Department of Health and Human Services

Incentive Receipt Form for Parent Focus Groups

I have received $75 for participating in a focus group for CommunicateHealth and the Office of Disease Prevention and Health Promotion (ODPHP).

Name (print):

Name (sign):

Date: