Institutional B: Participant Payment Plan

InstItutional b: Participant payment plan

*UTHSCSA IRB #:
(SECTION TO BE COMPLETED BY IRB STAFF)
PI Name / PI Point of Contact
Section 1: Payment Schedule
Visit or Event Description / Type of Payment
*Select from Dropdown* / Frequency of Payment
*Select from Dropdown* / Compensation Amount
Select an ItemHSC - Debit CardCashLocal/State VoucherGiftVA - Debit CardOther (Specify)N/A / Select an ItemOne-Time PaymentPaid for Each Visit Described / (USD)
Select an ItemHSC - Debit CardCashLocal/State VoucherGiftVA - Debit CardOther (Specify)N/A / Select an ItemOne-Time PaymentPaid for Each Visit Described / (USD)
Select an ItemHSC - Debit CardCashLocal/State VoucherGiftVA - Debit CardOther (Specify)N/A / Select an ItemOne-Time PaymentPaid for Each Visit Described / (USD)
Select an ItemHSC - Debit CardCashLocal/State VoucherGiftVA - Debit CardOther (Specify)N/A / Select an ItemOne-Time PaymentPaid for Each Visit Described / (USD)
Select an ItemHSC - Debit CardCashLocal/State VoucherGiftVA - Debit CardOther (Specify)N/A / Select an ItemOne-Time PaymentPaid for Each Visit Described / (USD)
Select an ItemHSC - Debit CardCashLocal/State VoucherGiftVA - Debit CardOther (Specify)N/A / Select an ItemOne-Time PaymentPaid for Each Visit Described / (USD)
Select an ItemHSC - Debit CardCashLocal/State VoucherGiftVA - Debit CardOther (Specify)N/A / Select an ItemOne-Time PaymentPaid for Each Visit Described / (USD)
Total MAX Compensation per patient: / (USD)
Timing of Payment
*Select from Dropdown* / Select an ItemAfter the completion of each study visitAfter the completion of the studyOther (Specify in comments) / Additional Comments
If you need additional Space please attach additional pages
Section 2: Additional Reimbursements
(i.e., Airfare, Gifts, Lodging, Meals, Mileage, Parking, Taxi Voucher/Fare, etc.)
For “Additional Reimbursement” that is variable, please provide the Maximum amount per Occurrence. / N/A
Additional
Reimbursement Type / Fee Type / Timing of Payment: / MAX Amount per Occurrence
Select an ItemAirFareGift Item (Please Specify)LodgingMealsMileageParkingTaxi Voucher/Fare / Select an ItemOne-Time PaymentPaid for Office Visits Only / Select an ItemAfter the completion of each study visitAfter the completion of the studyOther (Please Clarify) / (USD)
Select an ItemAirFareGift Item (Please Specify)LodgingMealsMileageParkingTaxi Voucher/Fare / Select an ItemOne-Time PaymentPaid for Office Visits Only / Select an ItemAfter the completion of each study visitAfter the completion of the studyOther (Please Clarify) / (USD)
Select an ItemAirFareGift Item (Please Specify)LodgingMealsMileageParkingTaxi Voucher/Fare / Select an ItemOne-Time PaymentPaid for Office Visits Only / Select an ItemAfter the completion of each study visitAfter the completion of the studyOther (Please Clarify) / (USD)
Select an ItemAirFareGift Item (Please Specify)LodgingMealsMileageParkingTaxi Voucher/Fare / Select an ItemOne-Time PaymentPaid for Office Visits Only / Select an ItemAfter the completion of each study visitAfter the completion of the studyOther (Please Clarify) / (USD)
Select an ItemAirFareGift Item (Please Specify)LodgingMealsMileageParkingTaxi Voucher/Fare / Select an ItemOne-Time PaymentPaid for Office Visits Only / Select an ItemAfter the completion of each study visitAfter the completion of the studyOther (Please Clarify) / (USD)
TOTAL MAX Additional Reimbursement Amount, per/Subject: / (USD)
Section 3: Additional Payment Milestones
Will Subjects receive additional compensation for Unscheduled Visits? / Yes No
Compensation amount per Unscheduled Visit: / (USD)
How will Subjects who do not complete their Visit be compensated? / Select an ItemSubjects will be compensated for incomplete visitsIncomplete Subjects will not be compensatedOther (Please Clarify)
How will Subjects who do not complete the Study be compensated? / Select an ItemOnly completed visits will be compensatedNo compensation if they do not complete studyOther (Please Clarify)
Section 4: Study Scope
Will UTHSCSA funds be used to pay participants?
-  (UTHSCSA Funds is defined as any funds used from a “UTHSCSA Project Account,” or any funds that are planned to be deposited into a “UTHSCSA Project Account,” with the intent of paying participant payments.) / Yes No
Will UTHSCSA employees manage or handle the participant payments? / Yes No

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