Human Subject Payment Receipt
The Ohio State University Human Subject Payment Receipt; Version 1.1 10/09/2008
Date__________________
Paid To: _________________________________________________$ _____________
Subject Number _________________________________
Check number if paid by check ____________________
Gift card number from back of gift card if paid by gift card ____________________
Human Subject Protocol #:________________ Project #: _____________
Payee Signature: ____________________________________
Authorized By: _____________________________________
Please note that this payment is taxable income and the recipient is required to
report this amount on federal and state tax returns.
This receipt should be maintained, confidentially, in the project files.