SUBJECT PAYMENT SCHEDULE / PARTICIPANT PAYMENT FORM
UTHSCSA Tracking Number:
Section 1: Payment Schedule
☐ Yes ☐ No
Will Subjects be compensated the same amount for Each Study Visit?
IF Yes to section 1:
Number of
Visits:
Type of Payment
Fee Type
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Select an item
Total Compensation per patient:
Timing of Payment:
MAX Amount
per Occurrence
(USD)
(USD)
Select an item
IF No to section 1: Please specify Payment Schedule below
Visit or Event Description
Fee Type
Select an item
Select an item
(USD)
Select an item
Select an item
(USD)
Select an item
Select an item
(USD)
Select an item
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(USD)
Select an item
Select an item
(USD)
Select an item
Select an item
(USD)
Select an item
Select an item
(USD)
Select an item
Select an item
(USD)
Select an item
Select an item
(USD)
Select an item
Select an item
(USD)
Select an item
Select an item
(USD)
Select an item
Select an item
(USD)
Select an item
Select an item
(USD)
Select an item
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(USD)
Select an item
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(USD)
Select an item
Select an item
(USD)
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Select an item
(USD)
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(USD)
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(USD)
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(USD)
Total Compensation per patient:
Timing of Payment:
Compensation
Amount
Type of Payment
(USD)
Select an item
If you need additional Space please attach additional pages
Version 1.2, 07/25/2014
Clinical Trials Office
UT Health Science Center at San Antonio
Page 1 of 2
SUBJECT PAYMENT SCHEDULE / PARTICIPANT PAYMENT FORM
Section 2: Additional Reimbursement
(i.e., Airfare, Lodging, Meals, Mileage, Parking, Taxi Voucher/Fare, etc.)
For “Additional Reimbursement” that is variable, please provide the Maximum amount per Occurrence.
Additional
Reimbursement Type
Fee Type
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Timing of Payment:
TOTAL MAX Additional Reimbursement Amount, per/Subject:
☐ N/A
MAX Amount
per Occurrence
(USD)
(USD)
(USD)
(USD)
(USD)
(USD)
☐ N/A
Section 3: Gifts
☐ Will Subjects be provided Gifts or other items of limited or no monetary value?
(Please Specify: Type and Approximate Value)
Section 4: Screen Failures
☐ Yes ☐ No
Will Screen Failures be compensated for visits completed?
Approximately how many Screen Fails do you expect locally?
Up to which Visit can a Subject Screen Fail?
Section 5: Unscheduled Visits
☐ Yes ☐ No
Will Subjects receive additional compensation for Unscheduled Visits?
Compensation amount per/visit:
(USD)
Section 6: Incomplete Visit Payment
How will Subjects who do not complete their Visit be compensated?
Select an item
Section 7: Incomplete Study Payment
How will Subjects who do not complete the Study be compensated?
Select an item
Section 8: Study Scope
Will UTHSCSA funds be used to pay participants?
(This would include any funds that are used from a “Project Account,” or that are deposited into a “Project Account,” to pay
participant payments)
☐ Yes ☐ No
Will UTHSCSA employees manage or handle the participant payments?
☐ Yes ☐ No
Version 1.2, 07/25/2014
Clinical Trials Office
UT Health Science Center at San Antonio
Page 2 of 2