THIS LOG MUST BE COMPLETED AND MUST MATCH EACH AUTHORIZATION/REQUEST FOR THE PURCHASE OF GIFT CARDS/GIFT CERTIFICATES

FORM

P-Cardholder Name P-Card # only last 4 digits

Paymentnet Transaction Post Date (gift cards purchased posting)

Printed Name - Person Receiving Gift Card Recipient Signature Signature

or or of person who disbursed
If confidential - ID/Identifying # If confidential note "On File"
# Gift Card or Certificate # Amount Date Disbursed UT Employee Y/N

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Total Disbursed

Note: A unique ID/Identifying # may only be used on Gift Card Log 1 when the research /participant protocol requires confidentiality of research/participating subjects. (see example below)
An additional separate log (Confidential Gift Card Log 2) listing the name and signature of the recipient of the gift card/certificate must be maintained by the PI or department , kept on file and available for audit
purposes, and the records retained according to the applicable retention regulations.
Confidential participants listing an ID/Identifying # will note "On File" in place of a signature in column F of this form and remaining fields completed as outlined on the form.

Example below for confidential participant/ see Confidential Gift Card Log 2 for coresponding example
XYZ125687 $50.00 Participant ID-1 6/1/2010 On file signature of John Doe
 CONFIDENTIAL GIFT CARD DISBURSEMENT LOG 2
To be maintained by the Department or PI and used in conjunction with the Gift Card/Certificate Disbursement Log 1
This log is to be used by the department to assist in the assignment of confidential ID numbers for anonymous particpants who are receiving Gift Cards/Certificates.
This log must be kept in the event of a request by an Internal or State Audit. The Confidential Gift Card Log 2 is not placed in the P-Card packet.

# Gift Card or Certificate # Amount ID/Identifying # (from Gift Log col A) Date Disbursed Participant Name (Print) Participant Signature

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Corresponding example of Gift Card Log 1 entry

XYZ125687 $50.00 Participant ID-1 6/1/2010 Sue Smith signature of Sue Smith