Notice: Instructions for filling out the assent form are written in BLUE.  DELETE all of the instructions before submitting the assent.  Delete this notice. Do not delete the IRB Stamp information.

This assent form is not valid without a TTUHSC El Paso IRB stamp in the lower left corner of each page.  
  
ASSENT TO TAKE PART IN A RESEARCH STUDY

This is a research study for people who choose to take part.  

STUDY TITLE:  (this may be simplified if necessary to allow a minor to understand)

We are trying to learn about [insert topic of study in simple language] because [explain research purpose in age-appropriate language].  If you would like, you can be in our study.

If you decide you want to be in our study, you will [explain all tasks and procedures clearly and simply].

[Explain the benefits and risks in clear, simple child-friendly language.

Other people will not know if you are in our study.  We will put things we learn about you together with things we learn about other [children, teens], so no one can tell what things came from you.  When we tell other people about our research, we will not use your name, so no one can tell who we are talking about.

Your parent(s) or guardian have to say it’s OK for you to be in the study.  After they decide, you get to choose if you want to do it too.  If you don’t want to be in the study, no one will be mad at you.  If you want to be in the study now and change your mind later, that’s OK too.  You can stop being in the study at any time.

Our telephone number is [study contact telephone number].  You can call me if you have questions about the study or if you decide you don’t want to be in the study any more.

We will give you a copy of this form in case you want to ask questions later.

Your Agreement

I have decided to be in the study. I know that I don’t have to do it.  My questions have been answered. 

Printed Name of Child	            Age of Child

			
Signature of Child	             Date

I have discussed this research study with the child and his or her parent/guardian/authorized representative, using language that is understandable and appropriate.  I have given a copy of this form to the parent/guardian/authorized representative.  

		
Printed name of authorized research personnel who
conducted the discussion and obtained assent

			
Signature of authorized research personnel who				Date
conducted the discussion and obtained assent