ࡱ> UXT bjbj B4ggj1@ @ 8Tr$;(:::::::$=e@:::F::6<68-B7::0;87`@@888@8::p;@@ X : Research Study Assent Form (11-14 Year Age Range) Name of Minor: _____________________________ Parental Permission on File: ( Yes ( No** **(If No, do not proceed with assent or research procedures.) Study Title: [Title as listed on IRB application] Researchers: List names and contact information of investigators and co-investigators My name is (insert the name of the person who will approach the child during the assent process). I am from ʯֱ. I am inviting you to be in a research study about (topic of the study in simple language) Example: what kinds of foods kids usually eat and how much exercise they get. Your parent knows we are going to ask you to be in this research study, but you get to make the final choice. It is up to you. If you decide to be in the study, we will ask you to (describe what the child will be asked to do in simple language that is appropriate to the childs age and maturity. If the child will be asked to do several things, describe each one. Explain about how long each aspect of their participation will take). Example: talk with us for about half an hour to answer some questions about your bedtime and how you go to sleep. (If media recording is to be part of the study, explain that here and let the child know that you wont record them without their permission) (Describe potential benefits to the child, if any, and those to society) Example: If you take part in this research study, you might learn how to choose good snacks and new games you can play outside. (Describe potential risks to the child, including fatigue, boredom, pain, anxiety, etc. in simple language. Also explain what you will do to minimize those risks or handle the risks if they occur.) Example: We dont think anything bad would happen if you decide to take part in this research study, but some kids might get tired of sitting still while they answer questions. We will let you take a break about every 15 minutes or more often if you need to. If anything in the study worries you or makes you uncomfortable, let us know and you can stop. (If relevant), There are no right or wrong answers to any of our questions. You dont have to answer any question you dont want to answer or do anything you dont want to do. Everything you say and do will be private. We wont tell your parents or anyone else what you say or do while you are taking part in the study. When we tell other people about what we learned in the study, we wont tell them your name or the name of anyone else who took part in the research study. (When relevant, the child should be informed that you must tell authorities or health professionals if you learn that the child has been hurt or might be hurt by another person, or might hurt themselves.) You dont have to be in this study. It is up to you. You can say no now or you can change your mind later. No one will be upset if you change your mind. You can ask us questions at anytime and you can talk to your parent any time you want. We will give you a copy of this form that you can keep. Here is the name and phone number of someone you can talk to if you have questions about the study: Name (researcher) Phone number (local phone number) Do you have any questions now that I can answer for you? IF YOU WANT TO BE IN THE STUDY, SIGN OR PRINT YOUR NAME ON THE LINE BELOW: (If relevant: Put an X on this line if it is okay for us to record you __________ _______________________________________ __________________ Signature of Minor Date _______________________________________ __________________ Signature of Researcher obtaining assent Date     Page  PAGE 2 of  NUMPAGES 3 !123;@Ccdp罨lll[[ll[G[G[[' jhlpghlpgB*OJQJ^Jph!hlpghlpgB*OJQJ^Jph$hlpghlpg5B*OJQJ^Jph!hth1B*OJQJ^Jph/h3 h15B*CJOJQJ\^JaJph)hx5B*CJOJQJ\^JaJph)h3 5B*CJOJQJ\^JaJph)h15B*CJOJQJ\^JaJph/hMh15B*CJOJQJ\^JaJph23d  a B tl & Fgd:  X` dxgd3  X` dx^`gd3  X`  d^` gd|^ X` dx^`gdlpg X` dx^`gd1$ X` da$gd3    8 ` a l ȷȣr_rrOr>!hth3{B*OJQJ^Jphh3 6B*OJQJ^Jph$hthL6B*OJQJ^Jph$hth3{6B*OJQJ^Jphhth3{OJQJ^J!h3 6B*OJQJ]^Jph'hth16B*OJQJ]^Jph!hth1B*OJQJ^Jph'hth15B*OJQJ\^Jph!hlpg5B*OJQJ\^Jph$hlpghlpg6B*OJQJ^Jph  A B C K N  ۢo\OOBO5hth<0OJQJ^JhthqOJQJ^Jhth"OJQJ^J$h"[h"[6B*OJQJ^Jphh8a6B*OJQJ^Jph$h"[hMj6B*OJQJ^Jphh3 6B*OJQJ^Jphh"[6OJQJ^J$hthMj6B*OJQJ^JphhthMjOJQJ^JhthW6OJQJ^Jhth3{6OJQJ^Jhth3{OJQJ^Jh"[OJQJ^JB J L N O )*h^hgdBgd"[ & Fgd: gdqh^hgdA;gd"[h^hgd3  & Fgd: 8^8gd"[ hh^h`hgd3    ! 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