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Approval #: ________
Expiration date: ______
Participants Initials: ____________
Document version: _________
Page PAGE \* Arabic \* MERGEFORMAT 1 of NUMPAGES \* Arabic \* MERGEFORMAT 2
Child Assent Form
Insert Study Title
My name is _______, and I am doing a study to learn about ______(e.g., how students learn in school).
We are asking you to be in this study because _____________. This research study will include roughly ______ participants.
We already told your parents about the study, and they said you can be in the study if you want to. If you dont want to be in the study, you can say No and nobody will be upset at you and nothing bad will happen. Also you can change your mind at any time and nobody will be upset and nothing bad will happen.
If you choose to be in the study, then you will (e.g., spend about 15 minutes answering some questions about what helps you learn better).
If you think you were treated badly or have any problems with this study, you should tell your parents and they will know what to do.
(Optional, depending on the nature of the study): You need to know that your name and what you tell me or what you do will not be told to any other adults. There is only one thing that I would have to share with someone else, and that is if I think you are in danger for any reason or if I see you hurt yourself or someone else on purpose. I will talk with you first before I talk to anyone else so that we can talk about what I thought happened and who I need to share the information with. I wanted to let you know that this might happen if you tell me that kind of information. Do you understand that?
Do you have any questions about the study?
Would you like to do it?
Statement of Assent
I have read and understand the information about this study, and I agree to participate in it. Its my choice to be in the study, and I can change my mind at any time.
I ___agree ___do not agree to be videotaped for this study.
Print Name of Participant:
Signature of Participant: Date:
Name of researcher obtaining assent:
Though children do not have the legal capacity to consent to participate in research, they should be involved in the process if they are able to assent by having a study explained to them and/or by reading a simple form about the study, and then giving their verbal choice about whether they want to participate or not.
Use non-technical language at a reading level appropriate to the participant. Check reading level at
https://support.office.com/en-us/article/Test-your-document-s-readability-85b4969e-e80a-4777-8dd3-f7fc3c8b3fd2
Explain why they are being recruited for the study.
Make sure to put the intended number of participants.
Explain what the participant will do in the study; include the anticipated time. If the intent is to audio-tape, video-tape, or take photographs, include that here
Complete this section for written assent.
If any audio, videotaping, or photography is taking place, you will need separate statements for each. Otherwise delete these check-off items):
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