ࡱ> wzvW PQbjbjqq paa4Sj j $   PZ 2`%&TV&,1111111$4C7\1'#`%''1K2 , , ,'F1 ,'1 , ,.` /`!`Uǫ=(R.1a202.,7(7 / /87X/8&>&, ,&$'&&&117*&&&2''''7&&&&&&&&&j B :  Human Subjects Payment Form  Fill out this form completely and send to your Business Services or ORSP Fund Accountant, depending upon funding source. If requesting cash, this form must be received at least 72 hours prior to pickup. If you do not provide the request 72 hours prior to pick up, you run the risk of the cash being unavailable in accordance with MOMs policy #326 Section V. Gift cards can only be purchased with cash. Cash can be picked up by an authorized individual in Business Services Treasury during normal business hours 9 a.m. to 4 p.m. Issuance of a check will follow standard University procedures. Printed name of requestor:  FORMTEXT      Today s date:  FORMTEXT      Department:  FORMTEXT      Phone:  FORMTEXT      E-mail:  FORMTEXT      Principal Investigator Name:  FORMTEXT      Purpose of Request: FORMTEXT      Time frame of project: FORMTEXT      IRB Approval # (Required for payment) FORMTEXT      Estimated Number of Subjects: FORMTEXT      Payment per Subject: $  FORMTEXT       Will any subject receive more than $600 in a calendar year?  FORMCHECKBOX  Yes, complete the check section below and do not include this amount in the cash requested.  FORMCHECKBOX  Yes, and ϻ IRB has approved under exempt category CFR 46.101 (b) 4 (e.g., anonymous) and research subjects are not limited to ϻ employees.  FORMCHECKBOX  No, complete the cash section below. NOTE: The income tax consequences of human subjects payments are entirely the responsibility of the individual. If a human subject is paid $600 per year or more, it is IRS-reportable by the University. CASH SECTION: Total Amount Requested:  FORMTEXT       Date Payment Needed:  FORMTEXT       Denominations:  FORMTEXT      Index #  FORMTEXT       Expense Code: 1904 (Cash will be initially coded to 1904-Other Advances and moved when supporting documentation is received on the  HYPERLINK "http://umt.edu/research/complianceinfo/IRB/Docs/Human%20Subjects%20Payment%20Form.doc" Human Subjects Payment & Certification Form.) Identify the secure site where the funds will be kept:  FORMTEXT      I authorize  FORMTEXT       to pick up the cash at Business Services Treasury. 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