Example of Assent Form - Michigan Technological University

Exhibit I: Example of Child Assent Form
Study of the Transitional Living Program
1. My name is May Flower and I am a student at Michigan Technological University.
2. My professor, Dr. Justin Time, and I are asking you to take part in a research study because we are
trying to learn more about how well the Transitional Living Program helps you learn things to make
your life easier.
3. If you agree to be in this study, I will ask you to do a few things over the next few weeks.
I will ask you questions about what you have learned here.
I will ask you questions about what you do in the program.
I will ask you questions about how you feel about being in the program.
I may make a videotape of you doing activities in the day room.
After you go home, I may contact you later to ask you some more questions. If I do, you will have the
chance then to decide whether you want to answer my questions.
4. I do not believe that you will be hurt or upset by being in this study. If you take part in the study and
believe that you have been hurt or upset in any way, you may stop being in the study. I will not tell
anyone else the things you tell me about the Transitional Living Program or anything you tell me
about yourself or any other person. But if you tell me that someone here is hurting you, I must report
it to the proper authorities.
5. This study probably will help you, but if you participate in this study, it will teach me important ways
to help other children like you in the future.
6. Please talk this over with your parents before you decide whether or not to participate. Your parent
gave permission for you to take part in this study. Even though your parent said “yes,” you can still
decide not to do this.
7. If you don’t want to be in this study, you don’t have to participate. Remember, being in this study is
up to you and no one will be upset if you don’t want to participate or even if you change your mind
later and want to stop. If you choose not to participate in the study you will be expected to complete
the assignment and it will not affect the grade you receive.
8. You can ask any questions that you have about the study. If you have a question later that you didn’t
think of now, you can call me at 906-555-4444 or ask me next time. You may call me at any time to
ask questions about the study.
9. Signing your name at the bottom means that you agree to be in this study. If you are not able to sign
your name, you do not have to. Your doctors and therapists will continue to treat you whether or not
you participate in this study. You will be given a copy of this form after you have signed it.
Signature of Subject
Printed Name of Subject
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