Human Subject Confidentiality Certification

Complete this form for the project that requires confidentiality of paid participants. This document must be attached to related a Chrome River Reimbursement Request or a HokieMart ISR.

Participant Information

*Participants are not listed due to human subject confidentiality*
*Indicates required field

Certification Statement & Signature

The Principal Investigator and department administration are responsible for making disbursements and securing the following minimum receipt documentation: date, name of the participant, and amount of compensation. When submitting reimbursement requests to the Controller's Office, the Principal Investigator and department administration will remove the participant's identifying information (name, email address, etc.) from the receipt documentation.

The Principal Investigator and department administration will store the participant's confidential information and record of payment in a secure location. The P.I. and department administration will attach proof of payment by the faculty member, proof of participant receipt, this form, and the Institutional Review Board (IRB) approval to any Chrome River reimbursement requests or HokieMart ISR. The P.I. and department administration will keep all disbursement records for at least seven years for tax and auditing purposes.

It is the P.I. and department’s responsibility to provide summarized information to the Controller’s Office for 1099/1042S processing when total payments to an individual, including confidential participants, are $600 or greater during a calendar year.

By my signature, I confirm the receipt document is on file within my department and I certify that I will comply with the conditions listed above.

Principal Investigator (Required):
Department Head/Approver (Required):