Sample Informed Assent

Sample Informed Assent

Dear Participant –

My name is ______and (your title) ______at Morehead State University in the Department of ______. I am requesting your assistance with a research project I am conducting on the ______. Let me emphasize that you do not have to take part in anything that makes you uncomfortable. If you do not wish to take part in this project (or any of the ______) you do not have to participate. This is true, also, for the attached questionnaire. You are free to refuse to answer any and all of the questions. Completing the survey is voluntary (up to you) and you can withdraw from the study at any time.

If you agree to participate in the ______, you will be asked to participate in the following ______:

-  ???????

-  ???????

This study has been reviewed to determine that participants’ rights are safeguarded and there appears to be minimal risk or discomfort associated with completion of the survey. You may choose to discontinue your participation at any time and you may refuse to answer any of the questions.

The answers you provide will be kept strictly confidential and all your responses (completed surveys) will be stored in a locked file cabinet accessible only to the researcher (______). This means that no one will be able to find out your answers or your responses to any of the questions. These records will be kept in ______Morehead State University, Morehead, Kentucky. Please feel free to ask for help if something does not make sense to you or if you have any questions. If you experience any discomfort, you may contact ______at (___) ___-____.

If you decide to volunteer, please be sure to PRINT your name on the form and to SIGN it to indicate your willingness to participate. That will be indication that you understand the purpose of the survey and that you are willing to help.

Name (Print): ______

Signature: ______

Signature of Legal Guardian: ______(if needed)

Date Signed: ______