Peds Residency Research Incentive Request

Use this form to request focus group/project participation incentives such as gift cards. Complete a new request for each batch of incentives. Do not use this form to request purchases for non-incentive items like supplies or equipment. You will need to provide the link to your expense tracker so have that ready before completing this form.

Human Subject Incentive Form

Before you get started, you are required to complete the Human Subject Incentive Form located at https://bit.ly/3rH8wq8. Requests for incentive payments will not be processed without this first being completed. Only one form is required per project.

I have submitted the Human Subject Incentive Form.*

Upload a copy below in the "File Attachments" section.

Date*

Name*

Email Address*

Title of Project*

Detailed Expense Description*

In 2-3 sentences, explain why your request is necessary for your project.

Type of Grant*

Select

Human Subject Incentive Amount*

Please include the quantity and dollar amount and preferred vendor of incentive (ie: 15 $5 Amazon gift cards).

Blurb to include with gift card (if applicable)

Some digital gift card services, like Amazon, allow custom messages to be included. If the incentive you're requesting allows custom messages, let us know what you'd like written, if anything (ie, Thank you for participating in our 'such and such' study!"

Human Subject Email Address

Names and/or email address of participants who should receive incentives. You may also upload an Excel spreadsheet of this information.

Expense Tracker

Provide the link to your expense tracker that lists all purchases requested, including today's request, whether or not the purchase has been made or is still pending. You may use this template or create your own. Please share the sheet so that anyone with the link can access it.

Purchases will not be made until we have this information.

File Attachments

Upload a copy of the Human Subject Incentive Form, human subject email addresses as well as grant application and award letter, if this is your first time requesting incentives.

Drag and drop files here or

Notes

Send me a copy of my responses

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