Sample Assent Form printable pdf download

Sample Assent Form

This sample is intended to help you create an assent document for a minor ages 11-17; the text

here is a suggestion for how to introduce the required elements of an assent form in a way that is

easy for a minor to understand.

Sample Minor Assent Document

Project Title:

Investigator:

We are doing a research study about purpose in simple language. A research study is a way to

learn more about people. If you decide that you want to be part of this study, you will be asked to

description, including time involved.

There are some things about this study you should know. These are procedures, things that take

a long time, other risks, discomforts, etc.

Not everyone who takes part in this study will benefit. A benefit means that something good

happens to you. We think these benefits might be description.

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 do not have to be in this study if you do not want to be. If you decide to stop after we begin,

that’s okay too. Nothing bad will happen to you. Your parents or guardian 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)

Parts in italics should be modified for your specific project. Other parts may need to be

modified as well depending on your research methods.

Sample Assent Form