Updated August 2014
Sample Assent Form
My name is (interviewer’s name. I am from the University of Chicago and I am doing an evaluation study of what young people in the [name] Summer Program think about the program. You have expressed an interest in being interviewed about this summer program. Your (mother/father/guardian) said it would be alright for me to ask you to be part of an interview. I am going to talk to about 300 other youth between the ages of 10 and 16, and about 200 parents about the summer program.
What will participation in this study entail?
The University of Chicago researchers would like to interview you about your interest in the summer program such as why you decided to join, what kind of training on employment skillsand career development you received, and questions about fitness activitiesyou participated in during this summer. I will also ask about your perspective on your social competence and peer relations. It will take about 45 minutes to one hour. The interview will be held at the community center, a café or at a University office. I would like to audio-record the interview if that’s okay by you.
Are there any small risks or for participating in this interview study?
Some of the questions I ask might make you uncomfortable or embarrassed but we will keep your answers confidential and you can skip any question you do not want to answer. You may quit the interview at any time without consequences or effects to your participation in the summer program.
Can anything good happen for participating in an interview?
I might find out something that can help summer program be better at servicing youth and their parents.
Who can you talk to about the study?
You can ask me questions any time. You can ask me now or later.
Will I tell anybody your answers?
All of the information that you provide will be kept private Only the people working with me on this study will see your answers. No one in your family or in the summer program will see your answers.
The three exceptions are if you are a victim of child abuse, you say you are going to hurt someone or hurt yourself I am required by law to report this to either the Department of Child and Family Services or to law enforcement.
What if you do not want to do this?
You do not have to be in this study. The interview is voluntary. No one will be mad at you if you do not want to participate in the interview. You can start the interview and quit anytime you want. If you don’t want to be in the study just tell me. If you decide to be in the study and don’t want to answer some of the questions you can skip them.
Will you get anything for being part of the study?
For helping me with this study, I am going to give you $10. If you decide to stop being in the study or skip some of the questions you still receive the cash.
Signing your name below shows that you agree to be in the study. If there is any part of the form that is unclear to you, be sure to ask questions about it.
Do you have any questions about this study?
[ ] Yes[ ] No
Do you want to take part in the study?
[ ] Yes[ ] No
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Signature of Child Date
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Person Obtaining Assent Date
If you have any questions later about the study, you can call me, ______, at xxx-xxx-xxxx.