Assent/Permission Template Instructions (delete this section and the other instructions/options
throughout this document before finalizing your consent form):
1. You may use this template or any other format as long as you cover all elements
listed on the Informed Consent Checklist.
2. If you choose to use this template, you do not have to submit the Informed Consent
Checklist to the IRB.
3. This format is recommended for minor subjects age 12 – 17. Write in language
appropriate to the subjects you are studying. Use lay terms. Use appropriate size font
for special populations.
4. Please leave enough of a margin on the bottom of the page to allow for the IRB’s
official approval stamp. You must use the stamped copy when you make copies for
the subjects to sign, so that you can show you used the version approved by the IRB.
5. If this is a multi-phase study where subject involvement may change or confidential
information may be handled differently as the study progresses, you may use one
consent form as long as you fully describe how things will change for each phase.
Assent/Permission To Participate In A Research Study
(Title Of The Study Here)
Message to Potential Research Participant:
You are being asked to help with a research project conducted by individuals at the
University of North Carolina Wilmington. The research activities are explained in detail
below for your parent(s). Since you are a minor, your parent(s) must give permission for
you to participate in the research. However, although you are too young to give legal
consent, you have the right to agree or disagree to participating in the research.
Agreement by a minor to participate in research is called “assent”.
If you do not want to participate in the research, your parent(s) cannot make you participate.
Also, if you decide you would like to help with this research, you can stop at any time and no
one will get mad or behave any differently toward you.
Please read the information presented to your parents below. If you agree to help with
this research, please sign on the last page.
Thank you for thinking about helping with this research.
Message to Parent(s)
Page 1 of 7
We are conducting research that involves minors. Since minors are not legally able to
consent to be research subjects, your permission is required along with the minor’s
agreement to participate. Detailed information about the research project is presented
below in question and answer format. Please read this information and ensure your child
understands the research activities before agreeing to participate. If you give permission,
and if your child agrees, please sign in the appropriate places on the last page.
Thank you for your consideration of this request.
What Is The Research About?
Your child is being invited to take part in a research study about ____________. There
will be about _____ participants in this study.
Who Is Doing The Study?
The person in charge of this study is ___________ (PI) of the University of North
Carolina Wilmington. If the researcher is a student add the following statement. UNCW
student, ___________ , will be gathering and analyzing the information for the study. If
relevant, add the following statement. There may be other people on the research team
assisting at different times during the study. If there will be student research assistants,
state this here.
Do Any Of The Researchers Stand To Gain Financially Or Personally From This
Research?
This research is being funded by ______________ (if applicable, name of funding
agency). None of the researchers participating in this study stand to gain financially or
personally. (If any of the researchers stand to gain financially or personally, other than
the grant award, explain the gain.)
What Is The Purpose Of This Study?
Describe the purpose of the study.
By doing this study we hope to learn__________.
Where Is The Study Going To Take Place And How Long Will It Last?
The research procedures will be conducted at ________ (state the general facility, such
as the child’s day-care center or school. If at UNCW, include the building and room
Page 2 of 7
number). Your child’s participation in the study will involve ______ visits with the
researcher. Each visit will take about ______ hours/minutes. The total amount of time
your child will be asked to volunteer for this study is _______ minutes/hours over the
next ______ days/weeks/months.
What Will My Child Be Asked To Do?
Describe all procedures in lay language, using simple terms and short sentences. Include
a time line for procedures that involve more than one visit.
If using randomization, describe this in lay terms. For example, “This is like tossing a
coin to determine who will be in which group.”
If child will be audio or videotaped, describe what will be involved, how tapes will be
stored, who will have access to them, and when they will be destroyed.
Are There Reasons Why My Child Should Not Take Part In This Study?
Only include this section if relevant.
State in lay language reasons why a subject could be excluded from the study. If your
study includes the administration of any substance other than wholesome food, and if the
statement is age-appropriate, you must include the following statement. Your child may
not participate in this study if she is pregnant or if there is a chance she may be pregnant.
What Are The Possible Risks And Discomforts?
If the research involves no more than minimal risks to the subject, include the following
statement. To the best of our knowledge, the things your child will be doing have no
more risk of harm than he or she would experience in everyday life.
If the research involves any procedures that could cause possible physical harm, describe
the risks in lay terms.
If the research involves any procedures that could cause possible emotional or mental
harm, include the following statement. Although we have made every effort to minimize
this, your child may find some of the questions we ask (or some procedures in the study)
to be upsetting or stressful. If so, we can tell you about some people who may be able to
help your child with these feelings.
If relevant, include the following statement. In addition to the risks listed above, your
child may experience a risk or side-effect that we cannot predict. During the course of
Page 3 of 7
this research, if we find out any new reason why your child may no longer wish to
participate, we will provide you and your child with that information.
Will My Child Benefit From Taking Part In This Study?
Your child will not get any personal benefit from taking part in this study.
Does My Child Have To Take Part In This Study?
If your child decides to take part in the study, it should be because he or she really wants
to volunteer. There will be no penalty and if your child chooses not to volunteer he or she
will not lose any normal benefits or rights. No one on the research team will behave any
differently toward your child if he or she chooses not to participate in the study. Your
child can stop at any time during the study and still keep the same benefits and rights.
What Will It Cost For My Child To Participate?
There are no costs associated with taking part in this study.
Will My Child Receive Any Payment Or Reward For Taking Part In This Study?
Your child will not receive any payment or reward for taking part in this study.
OR
Your child will receive ______ for taking part in this study. If your child should have to
stop participating before the study is over, he or she will be paid based on the amount of
time in the study or he or she will still receive the full amount, the gift certificate, etc.
Who Will See The Information My Child Gives?
Your child’s information will be combined with information from others taking part in the
study. When we write up the study to share it with other researchers, we will write about the
combined information. Your child will not be identified in these written materials.
If the study is anonymous, with names not linked to the information gathered in any way,
include the following. This study is anonymous. That means that no one, not even
members of the research team, will know that the information your child gave came from
him or her.
Page 4 of 7
If the study is confidential, with names linked to the information gathered, include the
following. We will make every effort to prevent anyone who is not on the research team
from knowing that your child gave us information or what that information is. Describe
in simple terms the effort you are making to protect the confidentiality of the information,
for example, names being kept separate from information, assigning ID numbers with
lists linking names and ID numbers kept in a locked file cabinet, information linked to
names kept in a locked file cabinet.
However, there are some circumstances in which we may have to show your child’s
information to other people. We may be required to show information that identifies
your child to people who need to be sure that we have done the research correctly, such
as the UNCW Institutional Review Board and (if relevant) the research funding agency. If
relevant, include the following statement. Moreover, the law may require us to show
your child’s information in court or to tell authorities if the information indicates child
abuse or danger to your child or others.
Can My Child’s Taking Part In The Study End Early?
If your child decides to take part in the study he or she still has the right to decide at any
time to stop. There will be no penalty and no loss of benefits or rights if your child stops
participating in the study. No one on the research team will behave any differently
toward your child if he or she decides to stop participating in the study.
If relevant, add the following statement. We will notify you and your child if he or she
should no longer participate in this study.
What Happens If My Child Gets Hurt Or Sick During The Study?
Only include this section if relevant.
For research involving more than minimal risk, include the following. If you believe your
child is injured because of something that is done during the study, you should call
________ (PI) at _______ (phone number) immediately. We will make sure your child
receives any needed care or treatment. However, it is important for you to understand
that the University of North Carolina Wilmington will not pay for the cost of any care or
treatment that might be necessary because your child got hurt or sick while taking part in
this study. That cost will be your responsibility.
What If I Have Questions Or My Child Has Questions?
Before you decide whether or not to give permission for your child to take part in the
study (parent) and before you agree to participate in the study (minor), please ask any
Page 5 of 7
questions that come to mind now. Later, if you have questions about the study, you can
contact the investigator, _________ (PI) at ________ (phone number). If you have any
questions about your child’s rights or your rights as a research participant, contact Dr.
Candace Gauthier, Chair of the UNCW Institutional Review Board, at 910-962-3558.
What Else Do I Need To Know?
I am required by federal law to provide you with a copy of this permission/assent form.
Other optional statements:
You may request a copy of the project summary or final report.
If possible the minor participant should also read this complete form. If this is not
possible, a description of the research in age-appropriate language should be read to the
minor participant. Make sure the minor knows that he or she does not have to
participate and that he or she can stop at any time. Insert description here.
Research Participant Statement and Signature
I understand that my participation in this research study is entirely voluntary. I may
refuse to participate without penalty or loss of benefits. I may also stop participating at
any time without penalty or loss of benefits. I have been given a copy of this assentpermission form to keep.
________________________________
Signature of minor giving assent to take
part in the study
________________
Date
________________________________
Printed name of minor giving assent to
take part in the study
Parental Permission and Signature
I give permission for my child to participate in this research.
________________________________
Signature of parent or legal guardian
________________
Date
Page 6 of 7
giving permission for the minor to take
part in the study
________________________________
Printed name of parent or legal guardian
giving permission for the minor to take
part in the study
________________________________
Name of person providing information to
the parent and minor
Page 7 of 7
________________
Date