ASSENT DOCUMENT
Project Title: [Title]
Investigator(s): [List Principal Investigator (name and degree) who will obtain
informed consent from subjects.]
I am doing a research study. A research study is a special way to find out about
something. I am trying to find out [purpose of study in simple language].
If you decide that you want to be in this study, I will ask you to do several things.
[Describe procedures simply.]
I want to tell you about some things that might happen to you if you are in this study.
[Describe risks – e.g., things that take a long time.]
Not everyone who is in this study will benefit. A benefit means that something good
happens to you. I don’t know if you will benefit. But I hope to learn something that will
help other people some day.
When I am done with the study, I will write a report about what I found out. I won’t use
your name in the report.
You do not have to be in this study. It is up to you. If you say okay now, but you want to
stop later, that is okay too. All you have to do is tell me.
If you want to be in this study, please sign your name.
I, ____________________________________, want to be in this research study.
(Print your name here)
_____________________________________
(Sign your name here)
_________________
(Date)
____________________________________
_________________
(Signature of Parent or Guardian)
(Date)
By signing, you are stating that you are willing to participate in this study and that you
have received a copy of the consent form.