MINOR VERBAL ASSENT FORM: AGES 5-11
Study Title: _____________________________________
Hi! My name is ___________________ and I am a student/I work at Gonzaga University. We
are doing a research study in order to find out ____________. This is done by asking people
_________________. While doing this, they ____________________________________.
If you agree to be in this study, you will be asked to ______________________________.
We will ______________________________________________________ and make sure
you are comfortable with everything.
Your mom/dad has said it is okay for you to help us in our research, but if you don’t want to
do it, you don’t have to. Nobody will be mad at you and you will not get in trouble. If you
start the test and decide you don’t want to finish it, you can stop at any time. Would you like
to be in the study?
______________________________
MINOR’S PRINTED NAME
___________
AGE
INVESTIGATOR/WITNESS: I confirm that the contents of this form were orally presented
and that I witnessed the minor subject’s understanding.
INVESTIGATOR/WITNESS NAME
INVESTIGATOR/WITNESS’S SIGNATURE
Date
GU Minor Assent Form 5-11 years
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