Model Assent Form - Supplement To Informed Consent Form For Children 7-18 Years printable pdf download

Model Assent Form - Supplement To Informed Consent Form For Children 7-18 Years

Annexure 3

Model Assent Form

(supplement to informed consent form - for children 7 - 18 years)

Project Title:

Investigator:

We are doing a research study about .....................................................(purpose in simple

language). A research study is a scientific way to learn more about people. In this study we will

be .............................................................. (description of the study - Procedures, Drugs to be

used, risks, discomfort, in simple language).

Everyone who takes part in this study will NOT benefit directly. A benefit means that

something good happens to you.

The possible benefits from this study might be

...................................................... (details of possible benefits of participation)

If you do not want to be in this research study, we will tell you what other kinds of treatments

there are for you. (for research projects that offer treatment or intervention.)

When we are finished with this study we will write a report about what was learned. This report

will not include your name or that you were in the study.

You can be in this study if you want to be. If you decide to stop after we begin, that’s okay too.

Your parents know about the study too.

If you decide you want to be in this study, please sign your name.

I, _________________________________, want to be in this research study.

___________________________________

______

(Sign your name here)

(Date)

___________________________________

______

(Signature of parent/ legally accepted guardian)

(Date)

___________________________________

______

(Signature of Witness)

(Date)

adapted from

Model Assent Form - Supplement To Informed Consent Form For Children 7-18 Years