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Receipt Form: Usability Test Compensation (Minor)

Please sign below to indicate that you have received the promised compensation for your child’s
participation in testing today.

Date: _________

Amount received: _________

Child’s name: ________________________________________________

Please print your name: ____________________________________________________

Please sign your name: ____________________________________________________

Thank you!

We appreciate your participation.

Test: (Site name) __/__/__ to __/__/__

U.S. Department of Health & Human Services - 200 Independence Avenue,


1
S.W. - Washington, D.C. 20201

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