LONG ASSENT FORM FOR A CHILD OR YOUTH (AGES 7-17)
[Title of Study]
We are inviting you to be in a research study. This form will give you the information you need to help you decide if participating is something you would like to do. The purpose of this study is[SPECIFY PURPOSE OF THE STUDY]. You can participate in this study because[SPECIFY HOW THEY WERE SELECTED]. In order for you to participate, your parent/guardian also has to provide permission.
If you agree to take part in this research project here is what will happen:
- [SPECIFY ALL THE DETAILS THAT WILL TAKE PLACE IN THE STUDY]
You are free to decide if you want to be a part of this study or not to be a part of this study. Even if your parents gave you permission, you are free to decide not to participate. It is your decision. Your decision will not influence...
You can skip any questions you don’t want to answer. You may get tired. You can take a break any time you want. Some questions may be frustrating or difficult. You can quit any time you want. If you quit, it will not be held against you in any way. If at any time the questions get too uncomfortable, you can tell us that that you want to stop. We can also help connect you with… so that you have someone to talk to about the questions on the forms.
You may be worried that your answers could get you in trouble or that other people will find out what you said. We will keep all the information you provide confidential. This means we will not share information with anyone else. We won’t write your name on any forms. We will use a research code number instead. This way, no one will be able to find out the information about you.
While we make every effort to keep your information private, there are two things we cannot keep private. If we become aware of abuse, or neglect, to you or any other child, we must report it to child protective services because this is required by the law. If we are concerned that you may hurt yourself or someone else, we are required to report it to the school administration, to get help for you and for anyone else that might get hurt.
We hope to use your information to help understand[SPECIFY THE GOALS OF THE STUDY]. There are no direct benefits for you if you agree to be in the study. By participating, you may help others[SPECIFY]. This research study is confidential, no one except the researchers will see your answers.
At any time you have any questions about this study, you can call the person who is reading this form to you. You can also talk to the persons in charge of this project. They are ______from Fordham University. You can call ______at ______. You can call ______at ____. You may also want to talk to someone about your rights as a research participant, please contact the University of Notre Dame Institutional Review Board (IRB), Notre Dame Research Compliance, (), phone (574-631-1461). You don’t have to give your name if you call. You can tell the person that you have some questions about the research study.
Sincerely,
Please turn to Page 3 to indicate your decision whether or not to allow your child to be a part of this research study. You can keep pages 1 and 2 for your information, whether you agree to be a part of the research study or not.
[Title of Study]
Please keep pages 1 and 2 of the parent consent form so you have information about the study and how to contact the investigators.
This study has been explained to me. I am checking the box below to show whether I agree to volunteer to take part in this study. I have had a chance to ask questions. I know that I can stop participating at any time. I also understand that if I have questions about the project I can call ___ or ___. If I have questions about my rights as a participant the University of Notre Dame’s IRB, Notre Dame Research Compliance at (574) 631-1461 or . I understand that my parent has a copy of the same information.
Please check the box below to indicate your decision about allowing your child to participate in this study and please sign this form at the bottom of the page.
I agree to participate
I do not agree to participate
______
Youth Participant SignatureDate
______
Youth Name (Please Print)
______
Class Level (e.g., Freshman, Sophomore, Junior, Senior)
1