Incentive Receipt Form for Child

Attachment N:

ODPHP Physical Activity Guidelines, 2^nd Edition

Incentive Receipt Form for Child and Adolescent 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 Child and Adolescent Focus Groups

My child has received $40 for participating in a focus group for CommunicateHealth and the Office of Disease Prevention and Health Promotion (ODPHP). I have received $35 for supporting my child’s participation..

Minor’s Name (Print):

Parent Name (print):

Parent Signature:

Date: