Human Research ProtocolAssent Form
Assent Form
Principal Investigator Click here to enter text.
Department Click here to enter text.
Protocol Number Click here to enter text.
Study Title Click here to enter text.
Co-Investigator(s) Click here to enter text.
Sponsor (if any) Click here to enter text.
Contact Persons
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If you are hurt from being in this research, you should contact Dr. ______at (304) ___-_____. (After hours contact: Dr. ______at (304) ___-_____). If you have any questions, concerns, or complaints about this research, you can contact Dr. ______or Dr. ______at (304) ___-_____.
For information regarding your rights as a person in research or to talk about the research, call the Office of Research Integrity & Compliance at (304) 293-7073.
Introduction
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You, ______, have been asked to participate in this research study, which has been explained to you by ______.
Purpose(s) of the Study
Explanation of the purpose of the study
Description of Procedures
This study will be done at ______. You will be asked to come and see the doctor, who will give you an exam and take about 3 tsp of blood. You will get some medicine. You will be asked questions. It will take about two hours for you to answer the questions. You may see the questions before signing this page. You do not have to answer all of the questions.
Discomforts
Some of the questions will be difficult and you may not enjoy trying to answer them. The medicine you take may make you feel sick while you are on the study. It may hurt a little when they draw blood.
Benefits
This study may not help you, but what they learn from the study may help other people.
Confidentiality
We promise that anything we learn about you in this study will be kept as secret as possible.
Voluntary Participation
You do not have to do this. No one will be mad at you if you refuse to do this or if you decide to quit. You have been allowed to ask questions about the research, and all of your questions were answered.
I willingly agree to be in this research.
Signatures
Signature of Subject
______
Printed Name Date Time
______
The minor has had the opportunity to have questions addressed. The minor willingly agrees to be in the study.
Signature of Investigator or Co-Investigator
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Printed Name Date Time ______
Fax: 304-293-3098
http://oric.research.wvu.edu / Chestnut Ridge Research Building
886 Chestnut Ridge Road
PO Box 6845
Morgantown, WV 26506-6845
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Subject’s Initials______
Date______