(System requirement:
Netscape Communicator 4.6 or above is required to download)
Assent
Form
University
of St. Thomas
[Insert
Title of Study]
I am trying to
learn about [insert topic of study in simple language]. If
you would like, you can be in my study.
I want to learn
more about [topic] because [Explain research question and purpose
in clear, lay language.]
You don’t
have to be in the study unless you want to. If you decide
you want to, [Explain all tasks and procedures clearly and
simply]. If you decide now that you want to be in the study
and change your mind later, you can stop at any time and no one
will be upset with you.
[Explain
the risks and benefits in clear, simple child-friendly language.
The direct benefits to the child must outweigh the risks.]
Other people will not know if you are in my study. I will put information I have about you with
information from other people in the study, so no one can tell
what information I got from you. When I tell other people
about my research, I will not use your name, so no one can tell
who I am talking about.
Your parents or
guardian have to say it’s OK for you to be in the study.
After they decide, you get to choose if you want to do it too. If
you don’t want to be in the study, no one will be mad at
you. If you want to be in the study now and change your
mind, that’s OK too.
My name is
[researcher name] and my telephone number is [researcher’s
telephone number]. You can call me if you have questions
about the study or if you decide you don’t want to be in the
study any more.
I will give
you a copy of this form in case you want to ask questions later.
Agreement
I have decided to
be in the study even though I know that I don’t have to do
it. The [name of researcher] answered all my questions.
______________________________ ________________
Signature of Study Participant Date
______________________________ ________________
Signature of Researcher Date