Form C - Assent Form printable pdf download

Form C - Assent Form

Form C – Assent form

For studies involving children aged 16 to less than 18 years, the child’s assent must be obtained in

addition to the parent’s or guardian’s consent. The respondent must sign a form which states that

the information sheet has been read and discussed with the investigator and that the subject agrees

to participate in the presence of parent or guardian.

Specimen – Assent form

Name(s) of the investigator/s:

Personal contact information of principal investigator/s:

Address of the institution where the study is to be carried out:

The title of the research project:

I ……………………. (the participant’s name ) have read the information sheet and understand

a. what the study involves.

b. that refusal to participate in the study will not affect my treatment or care in any

way.

c. that I may withdraw at anytime and it will not affect me adversely in any

manner.

I ………………….. (the participant) have had an opportunity to discuss the matters related to the

study and ask questions and they have been satisfactorily answered.

I therefore agree to participate in this study.

Signature of the participant:

Full name

Date

Postal address

Signature of the parent/guardian:

Full name

Date

Postal address

NIC No

I have been present while the procedure has been explained to the child and I have witnessed

his/her consent to take part in the study.

Signature of the witness:

(The witness should be a person NOT connected with the study)

Full name

Date

Postal address

Form C - Assent Form