For Participant Payment Approval from Accounting Services Please Complete the Following

For participant payment approval from Accounting Services please complete the following information and reply by e-mail to Lynn Herdzina. Lynn will review and get back to you as soon as possible. Thank you.

IRB Number:

Name of PI/Researcher:

Name of study:

Very brief description of what the research is about:

Indicate specific funding source ( i.e.: personal funds, or list University chartfield, other (please explain)):

Number of subjects:

Amount of each subject payment:

How much each participant will receive in total:

The university prefers payments be made with a check. For any other method of payment we need an explanation of why using that method is important to the research project before approval can be given. (Note that name, permanent mailing address and social security numbers are required for payment.)

Estimate of dates subject payments will start, and end:

Indicate your department/ and departmental fiscal contact:

Division:

Revised February, 2010