Interview Incentive Receipt

OMB No. 0910-0788

Exp. Date 05/31/2018

RIHSC No. 15-052CTP

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 privacy 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

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Beth Riggsbee
File Modified	0000-00-00
File Created	2021-01-21