Modified Payment Receipt RS10

RS10 – Payment Receipt

Population Assessment of Tobacco and Health (PATH) Study

Payment Receipt

Print Participant’s Name: __________________________________________________

The National Institutes of Health (NIH) and the Food and Drug Administration (FDA) appreciate your participation in the PATH Study. Please accept the following payment(s) as a thank you for participating.

Adult Participant

 Payment of $35 on a debit card will be made to you for the adult interview.

 Payment of $25 on a debit card will be made to you for providing cheek cells and a

urine sample at an interviewer visit.

 Payment of $25 on a debit card will be made to you for providing a blood sample at

a health professional visit.

By signing below, you acknowledge receipt of a debit card that you will use for this study. Each time you participate in an interview or give a sample, we will make additional payments to you. Remember that participating in all or any part of the study is fully voluntary.

Participant’s Signature: Interviewer’s Signature:

_________________________________ ________________________________

______ / ______ / ______ ______ / ______ / ______

Month Day Year Month Day Year

Note: Please allow 3 business days for your debit card to be activated. Your card will be active for 36 months. After 2 months, if any money is still on the card, a $3 fee will be deducted from it each month. You will be charged $1 for each bank teller cash withdrawal; you will be charged $1 each time you get cash back from a debit purchase.

Please call our toll-free number, 1-888-311-1819, weekdays between 9:00 am and 9:00 5:30 pm Eastern Time, if you have concerns or questions.

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