Template 3: Consent and Assent for Children
These templates are available on the website – please check that they have not been adapted before you
you’re your proposal to Ethics Committee.
http://www.sun.ac.za/english/faculty/healthsciences/rdsd/Pages/Ethics_application_package.aspx
Due to constraints of space we have chosen to only show the English format. On the website there are
Afrikaans and iXhosa examples.
Assent for Children
CHILD ASSENT TEMPLATE1
NB! DELETE THIS PAGE BEFORE ADAPTING THE TEMPLATE TO YOUR PROJECT!
Please note:
1. Children who are able to understand the basic concepts of research should be given the opportunity
to assent to a research study. Generally children between the ages of 7 to 17 should assent to
research. This is not a fixed rule and some children younger then 7 may well have sufficient insight
and understanding to give assent for a study.
2. If they refuse assent then this refusal should be accepted, even if the parents have consented. There
may be exceptional cases where this rule may not apply. The HREC should be consulted.
3. This template is specifically for 7-12 year olds and can be adapted to suit adolescents.
4. If you are including a wide range of children in your project you well need 2 different versions of
assent, one for younger children and a more detailed one for adolescents.
5. You can adapt the template to suit the needs of your specific project including deleting sections
which are seen as not applicable/appropriate.
6. This assent document must be used in conjunction with a parental Information Leaflet and Informed
Consent form, which should obviously cover the project in more depth and detail.
7. Once your project has been approved and you have a reference number, you should replace the
information in the ‘footer’ with your own information e.g. Project No…… Assent template Version 1.1;
Date 10.08.09.
1
With thanks to Anel Kirsten for graphics and layout.
STELLENBOSCH UNIVERSITY
FACULTY OF HEALTH SCIENCES
PARTICIPANT INFORMATION LEAFLET AND ASSENT FORM
TITLE OF THE RESEARCH PROJECT: Insert the title of your project. Simplify it if necessary.
RESEARCHERS NAME(S):
ADDRESS:
CONTACT NUMBER:
What is RESEARCH?
Research is something we do to find new knowledge about the way things (and people) work. We
use research projects or studies to help us find out more about disease or illness. Research also
helps us to find better ways of helping, or treating children who are sick.
What is this research project all about?
Explain your project in simple child friendly language. Adapt the information to the age of the children that
you plan to include.
Why have I been invited to take part in this research project?
Answer this question in simple language
Who is doing the research?
Identify yourself and explain who you work for and/or why you are doing the project
What will happen to me in this study?
Describe what the participant will be expected to do. Describe all procedures using simple terms and explain
any technical or medical terms.
Can anything bad happen to me?
Explain any possible risks to the child, using simple terms. If something might be painful, state this in the
assent. Explain that the child should inform his/her parents if they are sick or in pain as a result of being in
the study.
Can anything good happen to me?
Only describe known benefits to the subject. You may include any possible future benefits to others. If there
are no known benefits, state so.
Will anyone know I am in the study?
Explain in simple terms that the subject’s participation in the study will be kept confidential, but information
about him/her will be given to the study sponsor. (NOTE: This information may not be applicable in assent
forms for very young children).
Who can I talk to about the study? List those individuals the subject can
contact (including their contact details) if he/she has any questions or has any
problems related to the study.
What if I do not want to do this?
Explain to the participant that he/she can refuse to take part even if their parents have agreed to their
participation. Explain that they can stop being in the study at any time without getting in trouble.
Do you understand this research study and are you willing to take part in it?
YES
NO
Has the researcher answered all your questions?
YES
NO
Do you understand that you can pull out of the study at any time?
YES
NO
_________________________
____________________
Signature of Child
Date
PARTICIPANT INFORMATION LEAFLET AND CONSENT FORM
TITLE OF THE RESEARCH PROJECT:
REFERENCE NUMBER:
PRINCIPAL INVESTIGATOR:
ADDRESS:
CONTACT NUMBER:
You are being invited to take part in a research project. Please take some time to read the information
presented here, which will explain the details of this project. Please ask the study staff or doctor any
questions about any part of this project that you do not fully understand. It is very important that you are fully
satisfied that you clearly understand what this research entails and how you could be involved. Also, your
participation is entirely voluntary and you are free to decline to participate. If you say no, this will not affect
you negatively in any way whatsoever. You are also free to withdraw from the study at any point, even if you
do agree to take part.
This study has been approved by the Health Research Ethics Committee at Stellenbosch University and
will be conducted according to the ethical guidelines and principles of the international Declaration
of Helsinki, South African Guidelines for Good Clinical Practice and the Medical Research Council
(MRC) Ethical Guidelines for Research.
What is this research study all about?
 Where will the study be conducted; are there other sites; total number of participants to be recruited
at your site and altogether.
 Explain in participant friendly language what your project aims to do and why you are
doing it?
 Explain all procedures.
 Explain any randomization process that may occur.
 Explain the use of any medication, if applicable.
Why have you been invited to participate?
 Explain this question clearly.
What will your responsibilities be?
 Explain this question clearly.
Will you benefit from taking part in this research?
 Explain all benefits objectively. If there are no personal benefits then indicate who is likely to benefit
from this research e.g. future patients.
Are there in risks involved in your taking part in this research?
 Identify any risks objectively.
If you do not agree to take part, what alternatives do you have?
 Clearly indicate in broad terms what alternative treatment is available and where it can be accessed,
if applicable.
Who will have access to your medical records?
 Explain that the information collected will be treated as confidential and protected. If it is used in a
publication or thesis, the identity of the participant will remain anonymous. Clearly indicate who will
have access to the information.
What will happen in the unlikely event of some form injury occurring as
a direct result of your taking part in this research study?
 Clarify issues related to insurance cover if applicable. If any pharmaceutical agents are
involved will compensation be according to ABPI guidelines? (Association of British
Pharmaceutical Industry compensation guidelines for research related injury which are
regarded as the international gold standard). If yes, please include the details here. If no,
then explain what compensation will be available and under what conditions..
Will you be paid to take part in this study and are there any costs involved?
No you will not be paid to take part in the study but your transport and meal costs will be covered for
each study visit. There will be no costs involved for you, if you do take part.
Is there any thing else that you should know or do?
 You should inform your family practitioner or usual doctor that you are taking part in a
research study. (Include if applicable)
 You should also inform your medical insurance company that you are participating in a
research study. (Include if applicable)
 You can contact Dr ……………….………..….. at tel ……………………… if you have any further
queries or encounter any problems.
 You can contact the Health Research Ethics Committee at 021-938 9207 if you have any
concerns or complaints that have not been adequately addressed by your study doctor.

You will receive a copy of this information and consent form for your own records.
Declaration by participant
By signing below, I …………………………………..…………. agree to take part in a research study entitled
(insert title of study).
I declare that:

I have read or had read to me this information and consent form and it is written in a language
with which I am fluent and comfortable.

I have had a chance to ask questions and all my questions have been adequately answered.

I understand that taking part in this study is voluntary and I have not been pressurised to take
part.

I may choose to leave the study at any time and will not be penalised or prejudiced in any way.

I may be asked to leave the study before it has finished, if the study doctor or researcher feels it
is in my best interests, or if I do not follow the study plan, as agreed to.
Signed at (place) ......................…........…………….. on (date) …………....……….. 2005.
............................................................................
.........................................................................
Signature of participant
Signature of witness
Declaration by investigator
I (name) ……………………………………………..……… declare that:

I explained the information in this document to …………………………………..

I encouraged him/her to ask questions and took adequate time to answer them.

I am satisfied that he/she adequately understands all aspects of the research, as discussed
above

I did/did not use a interpreter.
declaration below.
(If a interpreter is used then the interpreter must sign the
Signed at (place) ......................…........…………….. on (date) …………....……….. 2005.
............................................................................
.........................................................................
Signature of investigator
Signature of witness
Declaration by interpreter
I (name) ……………………………………………..……… declare that:

I assisted the investigator (name) ………………………………………. to explain the information
in this document to (name of participant) ……………..…………………………….. using the
language medium of Afrikaans/Xhosa.

We encouraged him/her to ask questions and took adequate time to answer them.

I conveyed a factually correct version of what was related to me.

I am satisfied that the participant fully understands the content of this informed consent
document and has had all his/her question satisfactorily answered.
Signed at (place) ......................…........…………….. on (date) …………....………………..
............................................................................
.........................................................................
Signature of interpreter
Signature of witness
CONSENT FORM FOR CASE REPORTS2
For a patient’s consent to publication of information about them in a journal or
thesis
Name of person described in article or shown in photograph:__________________________
Subject matter of photograph or article:__________________________
Title of article:_________________________________________________
Medical practitioner or corresponding author:____________________
I_________________________________________ [insert full name] give my consent for this
information about MYSELF OR MY CHILD OR WARD/MY RELATIVE [insert full
name]:_________________________, relating to the subject matter above (“the Information”) to
appear in a journal article, or to be used for the purpose of a thesis or presentation.
I understand the following:
1. The Information will be published without my name/child’s name/relatives name attached
and every attempt will be made to ensure anonymity. I understand, however, that complete
anonymity cannot be guaranteed. It is possible that somebody somewhere - perhaps, for
example, somebody who looked after me/my child/relative, if I was in hospital, or a relative may identify me.
2. The Information may be published in a journal which is read worldwide or an online journal.
Journals are aimed mainly at health care professionals but may be seen by many nondoctors, including journalists.
3. The Information may be placed on a website.
4. I can withdraw my consent at any time before online publication, but once the Information
has been committed to publication it will not be possible to withdraw the consent.
Signed:__________________________________ Date: ______________________
Signature of requesting medical practitioner/health care worker:
_____________________Date:______________
2
Adapted from BMJ Case Reports consent form.