ASSENT FORM, AGES 13-17
Insert Title of Study
We are asking you to be in our research study. We do research studies to learn more
about how the world works and why people act the way they do. Your parent or
guardian has also given permission to let you participate in the study.
I am trying to learn about how [insert topic of study in simple language]. I want to learn more
about [insert research topic] because [Explain research question and purpose in clear, lay
language]. I would like to invite you to participate in my study. Your parent(s) or guardian(s)
have already been asked if they will allow you to participate in the study, and they know we
are asking you if you want to participate.
You don’t have to be in the study unless you want to. If you decide you want to participate,
we will ask you to do the following things: [Describe what the child will do in the study. Be
specific, but make sure that your description is written for the reading comprehension level of
the child. You may consider listing the tasks using bullet points or numbered lists. Include the
amount of time that is required for each task, session, or experiment and where these will take
place. For example, “You will answer some math questions in your classroom and it will take
ten minutes.” Also, you must include whether you will use audio recording, photography, or
video recording during the procedures].
If you agree to be in the study, you may be uncomfortable with the following: [Insert risks
which may cause discomfort]. We don’t think there are any risks to you in this study, and we
don’t think it will help you. [If there are risks involved in the study, describe the risks in ageappropriate language and what you will do to minimize the risks. Consider explaining the risk
using an example that the minor can relate to. Do not include compensation in an assent form
unless there is compensation to the child.]
The information you give me during the study will be kept private. Your name will not be
used, and the list linking the code name assigned to your real name will be destroyed after
all the data is collected so no one who reads about our study will know that you participated.
When I tell other people about my research, I will not use your name, so no one can tell who
I am talking about. I keep all computer documents password protected and papers locked up
so only I can see them. [Also indicate what information will be shared with their parent or
guardian, if applicable].
Your parents or guardians have given their permission for you to be in my study. You don’t
have to participate in the study unless you want to; it is completely your choice. If you don’t
want to be in the study, no one will be mad at you and there won’t be any consequences for
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not participating. If you want to be in the study now and change your mind later, that’s okay.
You can withdraw from the study without any penalties. Just tell me that you don’t want to
be in the study anymore. If you choose to stop participating before we are finished, any
answers you already gave will be erased.
If you have questions about the study, please contact:
My name is [researcher name] and my telephone number is [researcher’s telephone number].
My email address is [researcher’s email address]. You can call me or email me if you have
questions about the study or if you decide you don’t want to be in the study anymore.
I will give you a copy of this form in case you want to ask questions later.
Agreement
I have decided to be in the study even though I know that I don’t have to do it. The researcher
told me about the study and answered my questions.
__________________________________________________________
Signature of Study Participant
________________
Date
__________________________________________________________
Signature of Researcher
________________
Date
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