1. 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 -
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
OPT Form V1 (1-1) MAR 03