Receipt of Subject Payment Gift Certificates/Cards

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Presentation transcript:

Receipt of Subject Payment Gift Certificates/Cards OBSTETRICS & PERIO THERAPY STUDY Receipt of Subject Payment Gift Certificates/Cards This form must be completed upon receipt of monthly gift certificates/cards used for subject payments. When completed, please fax the form to the OPT Study Administrative Center at 612-626-3938. - Month Day Year Date of Receipt: Clinical Unit: Total number of Certificates/Cheques Received: Number of Certificates Received for: Walmart: Target: Cub Foods: Children’s Place: Pathmark Grocery: American Express: Upon receipt of the gift certificates/cards from the OPT Study Administrative Center, this clinical site accepts full responsibility for the proper handling, security and distribution of the certificates/cards and acknowledges financial responsibility for any loss or theft of these items. Name of Person Completing Form (Print): Signature of Person Completing Form: Once this form is completed, FAX a copy immediately to the Administrative Center at 612-626-3938. OPT Form 101 V1 (1-1) MAR 03