Assent by Minor Subject Nine Years of Age Or Older

HACKENSACK UNIVERSITY MEDICAL CENTER

ASSENT BY MINOR SUBJECT NINE YEARS OF AGE OR OLDER

You are being asked to agree to participate in this research study. You have the right to find out what is involved for you if you participate, and to tell your parent(s) whether you do or do not want to participate.

Your parents will also be asked to give permission for you to participate in this study.

You have a right to withdraw your assent at any time.

Dr. and your parent(s) have explained to you the procedures that are involved, and you understand them.

Dr. and your parent(s) have also explained to you potential discomforts, risks or inconveniences that may be involved if you participate.

You have asked any questions you have, and all your questions have been answered.

You understand everything that has been told to you.

Check one:

I agree to participate in this study.

I do not agree to participate in this study.

Child’s Name Child’s Age

Signature Date

Witness

Relationship of Witness to Child

The IRB has determined that assent of minor subjects may be waived for this

study. However, all procedures, risks, and discomforts have been explained to

the child.

Principal Investigator