Appendix A-4 - Telephone Survey Receipt of Payment Form

OMB Control No.: 0970-xxxx

Expiration Date: xx/xx/20xx

Appendix A-4: Telephone Survey Receipt of Payment Form

Date of Survey: ___________________

Time of Survey: ___________________

Name of Participant: ___________________________________

Name of Researcher: ___________________________________

Signature of Researcher: ___________________________________ Date ________________

Signature of Project PI: ___________________________________ Date ________________

The $25 check for participation in this telephone survey should be made payable to:

Name (of individual or organization) _____________________________

Address:

This information collection is voluntary and will be used to learn how Head Start and Early Head Start programs establish and implement their school readiness goals. 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. The OMB number for this collection is 0970-XXXX and expires XX/XX/XXX.