For EXAMPLE Purposes Only.
Researchers should modify and create forms that meet the needs of the research project.
Note: Assent forms should be written in language appropriate to the subject.
Department of
9201 University City Boulevard, Charlotte, NC 28223-0001
t/ XXX-XXX-XXXX f/ XXX-XXX-XXXX www.
Dear Parent,
This letter is to ask your permission for [if parents will participate in the study in some manner the parental consent should
address both the parent’s and child’s participation] (you and) your child to participate in a special research study called “The
Self Determination Research Project.” The study is being conducted by Ms. Jane Doe, a graduate student in the College of
Education at UNC Charlotte. We ask that you read this letter and ask any questions you may have before agreeing to allow
(you and) your child to be in this study.
Ms. Doe, your child’s after school activity coordinator, will be working with your child at school to complete a one-year
project designed to help with problem solving, goal setting, and self-help skills. This project is part of her graduate work at
UNC Charlotte. She will conduct the project under the supervision of her UNC Charlotte Responsible Faculty, Dr. Janet
Doe. Students who participate in the after-school program and who are nominated by the school principal are eligible to
participate.
What is the Self-Determination Research Project?
The project has two activities for your child (Role Play Scenarios and a Matching Cards Game) that will help them learn how
to solve problems and set goals. This information will help your child’s teacher develop strategies designed to prevent future
academic and behavioral problems.
How long will the project last?
Each activity will take approximately 20 to 30 minutes and will be done three days a week until the students master the skills.
Ms. Doe will work with your child’s classroom teacher to schedule appropriate times for participation to avoid any
disruptions to your child’s normal school program. The activities will involve only small groups of three students.
What will the students be asked to do in the Role Play Scenarios?
During small group sessions, students will be introduced to a scenario that focuses on problem solving, goal setting, or selfhelp. During the role play, Ms. Doe will show the group how to use each step.
At the end, Ms. Doe will review with the group the main issue, the steps taken in the role play, and discuss the solution or
outcome of the scenarios. Ms. Doe will also use a chart of the steps the students just used. A sample of role play scenarios
is attached.
What will the students be asked to do in the Matching Cards Game?
After the role play scenarios, the group will be presented with two decks of cards: one will be labeled “Scenario,” and the
other deck will be labeled “Solution.” The “Scenario” deck will include different situations for each participant to identify,
and the “Solution” deck will include the steps that match with the situation. Each student will be asked to match each
“Scenario” card with the correct “Solution” card.
What are the benefits of your child participating in the project?
Student may benefit from participation in the Self-Determination Research Project. We anticipate improvement in students’
behavior and social interaction with peers and teachers. The results of this study may help teachers find new ways to help
children with behavior and social interactions.
What are the risks?
We do not foresee any educational or psychological risks for your child. However, in any research project there may be risks
that are not currently known.
What are confidentiality procedures?
Ms. Doe will not need to access your child’s school records for this project. No real names will be reported in the results of
this project. The data sheets Ms. Doe collects will be kept in a secure file in the office of the UNC Charlotte Responsible
Faculty. Any electronic files will be stored on Ms. Doe’s password protected computer.
All parents of children nominated for participation in this project are being sent this letter to request permission for their child
to participate. The decision for your child to participate in this study is completely up to you. Your child will not be treated
any differently if you decide that you to not participate. If you decide that your child can be in the study, you are free to
withdraw your child at any time without penalty.
UNC Charlotte wants to make sure that all research participants are treated in a fair and respectful manner. If you have
questions about your rights as a study participant, contact the university’s Office of Research Compliance at (704)-687-1871.
If you have questions about the activities or need additional information, please contact Ms. Jane Doe at (704) XXX-XXXX,
or the Responsible Faculty, Dr. Janet Doe at (704) XXX-XXXX.
Thank you for considering this request.
(Signature area for PI/Student)
This form was approved for use on Month Day, Year for a period of one (1) year.
Permission Form
[Please check one box below and return this form to your child’s teacher in the attached envelope.
Keep the above letter for your records.]
□ I agree to allow my child to participate in the Self-Determination Research Project. I understand that this means he/she
will take part in activities to promote solving problems, setting goals, and advocating for his/her self.
□ I do not agree to allow my child to participate in the Self-Determination Research Project.
_____________________________________
Child’s Name (print)
_____________________________________
Parent’s Name (print)
_____________________________________
Parent’s Signature
______________________
Date