Incentive Receipt

Form Approved

OMB No. XXXX-xxxx

Exp. Date xx/xx/xxxx

ATTACHMENT 9: INCENTIVE RECEIPT

U.S. Food and Drug Administration

and

RTI International

Thank you for participating in the RESPECT Study. In appreciation of your participation in this important study, you are eligible to receive $10 in cash. Since maintaining the privacy of your information is important to us, please only put your initials on this form. The researcher will sign and date this form to certify you received (or declined) the cash incentive.

______ ___________________________________ _________ __ __ __ __ __

Initials Researcher Date Case ID

□ Accepted Cash Incentive □ Declined Cash Incentive

OMB No: 0910-XXXX Expiration Date: XX/XX/XXXX

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 1 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov