Attachment G - Incentive Payment Page

Carrier Maintenance Management, Incentive Payment Page

Public Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-XXXX. Public reporting for this collection of information is estimated to be approximately 45 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information.  All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

Instructions:

We appreciate you taking the time to complete this survey and would like to compensate you for your efforts. If you may receive compensation in accordance with your carrier’s compensation policy, please provide the below information. This information is being collected on a secure online portal and for compensation purposes only; your personal information will not be tied to your survey responses. You will receive a compensation check in the mail in approximately 4-6 weeks. Please note that in order to receive compensation for participating in this study you must complete the following information:

Compensation Information:

Full name:

Mailing address (preferred address for receiving mailed check):

Phone number:

Thank you again for your participation. If you have any questions regarding the study or your compensation, please contact Andrew Krum, Principal Investigator, (540)-231-0353, akrum@vtti.vt.edu.