Attachment MICS-15_Follow-up Interview Incentive Receipt_Final_9-13-12

Follow-up Interview Incentive Receipt
U.S. Department of Health and Human Services
and
RTI International
Thank you for agreeing to participate in a special study for the
National Survey on Drug Use and Health.

In appreciation of your participation in this important study, you are eligible to receive $30 in cash.
Since maintaining the confidentiality 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
□ Accepted Cash Incentive

_________
__ __ __ __ __ __ __ __ __ __ - __
Case ID
□ Declined Cash Incentive

If you ever feel that you need to talk to someone about mental health issues, you can contact the 988 Suicide & Crisis
Lifeline. Counselors are available to talk at any time of the day or night and they can give you information about
services in your area.
988 (call or text)
1-888-628-9454 (Spanish)
http://988lifeline.org/
If you ever feel that you need to talk to someone about drug use issues, you can call the Substance Abuse and Mental
Health Services Administration’s National Helpline. This is a 24-hour service that will help you locate treatment options
near you.
1-800-662-HELP (4357)
1-800-487-4889 (TTY)
http://findtreatment.gov
Disposition: Top copy to Respondent, yellow to Field Supervisor, pink to Field Interviewer.