EXHIBIT B Participating Site Invoice PARTICIPATING SITE: ______________________________ INVOICE NUMBER: __________________________ INVOICE DATE: _____________________________ Within 90 days of completion of each item listed below, please submit an invoice to AHA. Item Quantity Unit Cost Unit Rate Previously Amount Due Invoiced this Invoice Start-up Costs $500 Lump Sum IRB submission $2,500 Each – Year 1 IRB submission $1,250 Each – Year 2 Completion of $500 Lump Sum Training Module Subject Enrollment $400 Each 22.7% of $400 $90.80 Each Facilities and Patient Administrative costs (per patient) Subject questionnaire $50 Each completion in Patient Patient Reported Outcomes Tool ISC Attendance $500 Each – Year 1 ISC Attendance $500 Each – Year 2 Total Total Total Amount Amount Previously Due this Invoiced Invoice
EXHIBIT B Participating Site Invoice PARTICIPATING SITE: ______________________________ INVOICE NUMBER: __________________________ INVOICE DATE: _____________________________ Within 90 days of completion of each item listed below, please submit an invoice to AHA. Item Quantity Unit Cost Unit Rate Previously Invoiced Amount Due this Invoice Start-up Costs $500 Lump Sum IRB submission – Year 1 $2,500 Each IRB submission – Year 2 $1,250 Each Completion of Training Module $500 Lump Sum Subject Enrollment $400 Each 22.7% of $400 Facilities and Administrative costs (per patient) $90.80 Each Patient Subject questionnaire completion in Patient Reported Outcomes Tool $50 Each Patient ISC Attendance – Year 1 $500 Each ISC Attendance – Year 2 $500 Each Total Total Amount Previously Invoiced Total Amount Due this Invoice