D. Assent Forms for Use With Minors
Date of preparation
Title of Study in Language Suitable for Children 7 - 12 Years of Age
My name is ____________, and I am inviting you to help me out with a project. Your parents
have said it is OK for me to talk with you about it. Before I explain more about the project, I
want you to know that the choice to do the project is completely up to you. No one is going to
force you to do something you decide you do not want to do. Even if you start the project and
decide part of the way through that you no longer want to continue, all you have to do is let me
know this, and we will stop.
Let me tell you about what you will be asked to do if you decide to help me out.
(Describe the purpose of the study, the tasks involved, and specify the length of time it might take
to complete the tasks using language appropriate for the age group you are targeting-if you
audiotape or videotape, you need to indicate that you will be using these methods of data
collection)
If you get bored or tired during our meeting, just let me know, and we can take a break. If you
are bothered by some of the things we talk about, let me know so we can talk about what is
bothering you. Most of the time what you say to me will not be repeated to your parents unless
you wish for me to do so. The only exception would be if I feel your parents might be helpful to
you if they knew what was going on. If such information comes up, we will talk about it before I
speak with your parents. Also, I may need to tell your parents or other people if I hear that you
are being hurt or abused, or you tell me that you want to hurt yourself or somebody else.
By helping me out with this project, you may not find out information that will be of help to you,
but what I find out from you may help us figure out how to help others.
When the results of this project are presented, the names of the children and families
participating in the study will not be revealed.
If you have any questions, you may contact me at (provide contact information).
You may keep a copy of this form if you wish.
_____________________________
Child’s signature
_____________________
Date
_____________________________
Researcher’s signature
_____________________
Date assent obtained
Date of preparation
Title of Study in Language Suitable for Youth 13 - 17 Years of Age
My name is __________, and I am a [student/faculty/other] in [name of subject] at Pepperdine
University [name of school]. Your parents have given me their permission to speak with you
about a study I am conducting on (explain what you are studying in a language appropriate for
this age group). I would like to invite you to participate in this study if you are interested.
Before I explain more about the study, I want you to know that the choice to participate is
completely up to you. No one is going to force you to do something you are not interested in
doing. Even if you start the study and decide that you are no longer interested in continuing, just
let me know and we will discontinue the study.
Let me tell you about what you will be asked to do if you decide to participate in this study.
(Describe the tasks involved and specify the length of time it might take to complete the tasks
using language appropriate for the age group you are targeting-if you audiotape or videotape,
you need to indicate that you will be using these methods of data collection)
If you get bored or tired during our meeting, just let me know, and we can take a break. If you
are bothered by some of the things we talk about, let me know so we can talk about what is
bothering you. Most of the time what you say to me will not be repeated to your parents unless
you wish for me to do so. The only exception would be if I am convinced your parents might be
helpful to you if they knew what was going on. If such information comes up, we will talk about
it before I speak with your parents.
Your participation in this study may not provide information that will be helpful to you, but what
is hoped is that what I find out from you may be of help in the future to others who are
undergoing a similar experience.
When the results of this study are published or presented to professional audiences, the names of
the people who participated in the study will not be revealed.
If you have any questions, you may contact me at (provide contact information).
You may keep a copy of this form if you wish.
_____________________________
Youth’s signature
_____________________
Date
_____________________________
Researcher’s signature
_____________________
Date assent obtained