Research Incentive Payment Request

Your Role*

PI
Grad Student or PostDoc
Other

Role if you selected "Other" above:*

Your Name*

First Last

Email*

Phone*

I would like to:*

Place a Research Incentive Payment Request for an Amazon eGift card.
Place a Research Incentive Payment Request for a mailed gift card.
Place a Research Incentive Payment Request for a specialty eGift card.

The participant has indicated that they would like an Amazon eGift card to be emailed to them. Please populate their selected gift card vendor and amount of the gift card in the field below.

Please instruct your participant to navigate to Amazon.com and enter “Specialty Gift Cards” into the main Amazon search box at the top of their web page. The participant may select from any merchant gift card option which has an available custom amount option. Please populate their selected gift card vendor and amount of the gift card in the field below.

Please instruct your participant to navigate to Amazon.com and enter “Specialty Gift Cards” into the main Amazon search box at the top of their web page. The participant may only choose an eGift Card from eGift Card merchants who offer that option if they would prefer the electronic gift card be emailed to their designated email address. Please populate their selected gift card vendor and amount of the gift card in the field below.

Select PI Name(s)*

Project(s)/Phase(s) to Charge*

Please click the plus sign button at the end of the row to add additional rows.

Project ID	Gift Card Vendor	Dollar Amount ($) to be charged to this ID

3:00 p.m. Daily Approval Deadline Acknowledgment

3:00 p.m. Daily Approval Deadline*

ASSIST Purchasing will process all orders received and approved by a Principal Investigator (PI) before 3:00 p.m. on the same day they are received. On occasions where Holiday schedules or University closures are in effect (denoted in the red box above), deadlines will be adjusted accordingly.

Yes, I understand my order must be received and approved by a PI before 3:00 p.m. to be processed on the same business day. FedEx label requests after 3:00 p.m. are subject to the same daily approval deadline and will be processed the following business day.

One request form is required for each Research Incentive Participant. Do not group together requests.

Provide the Payee's Status*

NCSU Undergraduate Student
NCSU Employee (GRA, Post Doc, Other)
Other (non-affiliated participant)

Participant Name*

First Middle Last

NCSU ID #

Include if participant is an NCSU student or employee.

Address (as listed with NCSU Cashier’s Office)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Participant Email*

IRB Protocol #*

Date of Participation*

Dates of Study

Start*

End*

Purpose of Research Incentive Payment*

Ex. “Compensation of $10 Amazon gift cards for participation in the study of wearable physiological sensors.”

Optional Comments

Comments – Optional

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S. Venkatesh
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