Participant Payments Intake

Participant Payments Intake

Request Information

Date of Request*

Requester Name*

First & Last

Requester Email*

Department/Business Unit*

Select

If Department/Business Unit is "Other", please specify:*

Dept Approver Name*

First & Last

If you are unsure who this person should be, please contact your department administrator or research administrator.

Dept Approver Email*

Study Information

Is Protocol in OnCore?*

Select or enter value

OnCore Protocol No*

Payments Protocol No*

80 Character Limit

[PI Last Name]_Short title_ProtocolID

i.e. Smith_Colitis_EUREKA2

IRB Number*

Enter "IRB Exempt" if the study is exempt and you do NOT have an IRB number

Short Title*

Anticipated First Payment

Anticipated Last Payment

Funding Information

WISER Project Number*

i.e. AAA9999

WISER UDDS*

i.e. 533400

WISER Fund*

Select or enter value

WISER Program*

Select or enter value

Different Account for Fees?

Check this box if you want to use a separate account for the transaction fees.

Fees WISER Project*

i.e. AAA9999

Fees WISER UDDS*

i.e. 533400

Fees WISER Fund*

Select or enter value

Fees WISER Program*

Select or enter value

Payment Type*

Select all that apply

Stipend

Travel Reimbursement

Payment Details*

i.e. $50/visit, mileage at the IRS rate, hotel up to $X, etc.

Will Participants receive more than $250 in a calendar year?*

NOTE: If participants will be paid more than $250 in a calendar year, W9 forms will be required from the Participants, and Participants will need to be added as Suppliers to ShopUW+

Yes

Financial Roles

Reviewer*

This individual will review the first stipend request for each Participant to confirm the Participant is set up correctly and linked to the correct study.

May also create supplier profiles in ShopUW+ for participants if payments exceed $250. May assist the Custodian with QA, audits, reconciliations, or other reviews as determined by the department.

NOTE: The Dean's office will review ALL travel reimbursement requests.

This individual MAY be the same as the Finance Coordinator. Example Roles: Financial Specialist or Accountant.

Enter email:

Finance Coordinator*

This individual will set up the study in Participant Payments once approved by the Department and SMPH. This will include populating study visits, setting up stipend amounts and travel reimbursement criteria, and adding study staff to the protocol. May also create supplier profiles in ShopUW+ for participants if payments exceed $250.

This individual MAY be the same as the Reviewer. Example Roles: Financial Specialist or Accountant.

Enter email (may enter more than one email separated by commas):

Pay Participants*

This individual will document the Participant's visit and request payment in Participant Payments.

This individual MAY be the same as the Finance Coordinator, but MAY NOT also be a Reviewer. Example Role: Study Coordinator, Data Coordinator

Enter email (may enter more than one email separated by commas):

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