[Title of Study]

Assent Form

(verbal for young children; written for older children)

My name is [researcher name]. I am trying to learn about [insert topic of study in simple language] because [explain research purpose in age-appropriate language].  If you would like, you can be in my study. 

If you decide you want to be in my study, you will [explain all tasks and procedures clearly and simply]. 

[Explain the risks, if any, and benefits in clear, simple child-friendly language. The benefits must outweigh the risks.]

Other people will not know if you are in my study.  I will put things I learn about you together with things I learn about other [children, teens], so no one can tell what things came 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 later, that’s OK. You can stop at any time. 

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 anymore.

I will give you a copy of this form in case you want to ask questions later.

(include a signature line (below) for older children)

Participant Agreement

I have decided to be in the study even though I know that I don’t have to do it.  [Name of researcher] has answered all my questions. 

______________________________                             ________________

Signature of Study Participant                                     Date

______________________________                             ________________

Signature of Researcher                                             Date