VERIZON MOBILE VISION CARE PROGRAM: CHILD ASSENT FORM
Verizon, OneSight and the SUNY College of Optometry are doing a research study. A research study is a special way to learn about something. We are doing this research study because we want to learn about different ways of finding whether children need to wear glasses.
WHY AM I BEING ASKED TO BE IN THIS RESEARCH STUDY?
You are being asked to be in this research study because we want to test children who take part in a school vision screening. We want to find out how well the mobile Autorefractor works as well as what impact vision care may have on school performance.
WHAT WILL HAPPEN DURING THIS RESEARCH STUDY?
You will go through a vision screening including looking at an eye chart and looking into a mobile Autorefractor. The mobile Autorefractor will shine a red light into your eye. All you have to do is look at a target across the room. The task will take less than a minute for each eye. If you end up needing further care, you will be able to attend a vision clinic to get an eye exam and glasses. At this vision clinic we may have you take part in a survey to understand how/what you are seeing. Sometimes things happen to people who are in research studies. These things are sometimes called “risks.” There is a risk that your eye might get a little tired when looking at the far target.
ARE THERE ANY BENEFITS TO BEING IN THIS STUDY?
The information that we learn from this study may help us be better at finding out whether children need to wear glasses. If we find out that you need further care, you will be able to attend a vision clinic to get an eye exam and glasses.
WHOM CAN I ASK IF I HAVE ANY QUESTIONS?
If you have questions about any of the procedures that will be done, or about anything else, you should ask the person doing the vision screening to explain before you agree to be in the study. Also, if you have any questions that you don’t think of until after you are in the study, you can always ask later.
WHAT IF I DON’T WANT TO BE IN THE STUDY?
If you don’t want to be in this study, you don’t have to be in it. It’s up to you and your parent or guardian. If you say you want to be in the study and then you change your mind, that’s okay too. All you have to do is tell us that you don’t want to be in it anymore. No one will be mad or upset with you if you don’t want to be in this study. You can still go through the vision screening with your classmates whether you are in the study or not.
CHILD signature: ______
PRINT CHILD name: ______
Investigator Signature:______
PRINT Name of investigator:______
DATE: ______
Page 1 of 1 Version June 2016