Human Subjects Receipts Summary Form

Use this form to request petty cash reimbursement for human subject research. For each expense, an individual must submit original receipts to the fund custodian, and sign off on the Human Subjects Receipts Summary Form upon receipt of reimbursement. The custodian must manage the reimbursement process.


  1. Payments or reimbursements indicated on this form should not exceed allowed amounts (but may be more than $80 if approved by Office of the Controller). For reimbursements, original receipts should be attached. If missing or lost receipts, such expenses should be fully explained.  
  2. For human subject incentive payments, the study coordinator should distribute the cash to the subject and prepare 3 part IRB receipt (not this one) for the subject to sign. All receipts/logs for human subjects need to be HIPAA compliant. Name and signature of study subject are considered confidential subject information and should NOT be included on any receipt or log submitted to Accounts Payable. Such information should be kept at the research site as part of the permanent confidential records.
  3. Use this form to outline payments for replenishment. Custodian must sign each page.    
  4. Attach to replenishment Check Request Form. Process in AP/CAR. See PC Info website for more detailed instructions.