Child Assent Form to Participate in a Research Study

Investigator’s Name:

Project #

[Fill in all blanks and remove all italics before submitting the form to the IRB.]

Study Title:

This is a study about ______(Insert general statement about the study).

Why YOU are invited

You are invited to be in this study because ______(Include a brief explanation of why the participant is being selected to take part in the research).

What will happen?

If you agree to be in the study, you will be asked to do the following things: (Explain procedures and task; identify any procedures that are experimental; describe length of time for participation, frequency and duration of procedures)If appropriate, include a sentence that indicates if the child’s parent will be present during participation in the research.

Can anything good happen to me?

Explain any possible benefits to the subject, using simple terms. (If there are no expected benefits, state as such).

Can anything bad happen to me?

Explain any possible risks to the subject, using simple terms. If something might cause harm, state this in the assent. Explain that the subject should inform his/her parents if they feel bador feel painas a result of the study.

What if I don’t want to do this?

If you say you do not want to be in the study, you just have to tell us. No one will be mad at you. You can also say yes and later if you change your mind, you can quit the study. The choice is up to you [and your parent(s)].Describe any alternative procedures that might be available to the subject other than this study, if applicable.

Who will ______(know my answers, see my information)?

Explain in simple terms that the subject’s participation in the study will be kept confidential.

We will do our best to make sure that(your answers to these questions/your information) are/is kept a secret. Your parents or guardian will get the information. If applicable, explain that the company who is paying for the study will get the information but your name will not be included.

Who can I talk to about the study?

You can ask questions any time. You can ask now. You can ask later. You can talk to me or you can talk to someone else, at any time during the study. Here is the telephone number to reach us XXX-XXX-XXXX. Provide Name and Department.

Do you want to be in the study?

YES NO

______

Signature of ChildDate

A copy of this form will be given to you.

*Remove the signature line if you propose to obtainassent without written documentation

University of Missouri Child Assent Form Template

Released: April, 2013