HSIP Request
Cards and Check can ONLY be mailed at this time.

Please be aware HSIP request take approximately 4 days to process. Missing information will cause a delay in the processing the request.

If the incentive will be mailed directly to the subjects,  please send the spreadsheet via DropBox. If social security numbers are required, please contact us, UM-Flint.HSIP@umich.edu, to setup a secure folder in DropBox
Sign in to Google to save your progress. Learn more
Email *
Principal Investigator *
Has the PI along with the Alternate Custodians completed the Cash Handling Training in My LINC? *
HSIP requests will not be processed until the training is completed by the PI and Alternate Custodians. To access this training, go to Wolverine Access, select My LINC (Learning & Information Center), and search for the TME103 Treasury Management - Cash Handling Course.
Date Needed
MM
/
DD
/
YYYY
HUM Number *
Shortcode *
Amount Requested. Only request an amount that will be distributed within 30 days. *
Clear selection
Number of Incentives *
Amount of each incentive
Payment Type. Cards  can be mailed to  participants or picked up by the Project Team in Ann Arbor. *
How will these be distributed to the subjects?  *
Who will be picking up the HSIP request? Please include at least one alternate custodian.
Special Instructions
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of University of Michigan. Report Abuse
Google Forms