[Title of Study]
(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
[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 itís OK for you to be in the study.
After they decide, you get to choose if you want to do it, too. If you
donít 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,
thatís OK. You can stop at any time.
My telephone number is [researcherís telephone
number]. You can call
me if you have questions about the study or if you decide you donít want
to be in the study anymore.
I will give you a copy of this form in case you want to ask questions
(include a signature line (below) for older children)
I have decided to be in the study even though I know that I donít have to
do it. [Name of researcher]
has answered all my questions.
Signature of Study Participant
Signature of Researcher