Section 701-03
CASH PAYMENTS TO HUMAN SUBJECTS

CERTIFICATION OF PAYMENT TO ANONYMOUS PERSONS

1.	ADMINISTRATIVE INFORMATION

a.	Account/Object to be charged:	     _____ - ________ -  _________ - ________ - ____ -     _______ - _______
		Chart	Account	Sub-Acct	   Object	   Sub-Obj  Project      Org Ref ID	

b.	Has a cash advance been issued?	No        	  Yes          - attach copy of check request

	c.	IRB approval number or exempt registration number:                                                                              

d.	Principal Investigator Name:                                                                                   

	e.	Department/Unit Name:                                                                                           

2.	DISBURSEMENT CONTROL RECORD (please print)

Line No.	
Date Paid	
Cash or Check	
Check No. 	
Human Subject
ID Number 	
Amount Paid	
Paid By:	

    1	

		

    2	

		

    3	

		

    4	

		

    5	

		

    6	

		

    7	

		

    8	

		

    9	

		

  10	

		

Page ____ of  ____			
Page Total		

Grand Total	

3.	I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT.

                                                                            		                            
     Principal /Co-Principal Investigator				Date

Rev. 8/17