IRB ASSENT FORM (SAMPLE)
For Children to Agree to Participate in Research
IRB No.:
Instructions: Assent means agreement by persons who do not have legal responsibility for their own activities, e.g.,
children. Assent by children must be accompanied by parental permission (consent). Assent is obtained from the children
who participate in research unless they are not capable of understanding what is being asked of them. The purpose of assent
is to insure that the subjects know what they are getting into and what effects their participation is likely to have. The form
should be written to suit the cognitive level of the group being asked to participate in the study. In some situations, the PI
should read the assent form and discuss the study with the child. Modify this form as necessary to suit the age group and
your study as appropriate. If assent is requested of and not granted by a child, the child’s refusal to participate in the
research is binding. A copy of this form must be provided to the study participant after signing it and the original is
retained by the PI.
Date:
Project Title:
Investigator:
This form has been approved for use by the UMass Lowell IRB and is valid for a period not to exceed one year
from the approval date.
Authorized IRB Approval Signature
Approval Date:
Statement: My parent/guardian knows about this study and wants me to be in the study, if I want to. I do want
to be in the study. I know that I can stop being in the study at any time I choose. I know that the researcher can
talk about the study with my parent/guardian at any time, but will not talk about it with anyone else who is not
working on the study unless I and my parent/guardian say it is okay. I can call the researcher at any time if I
have any questions. Circle the appropriate face below and/or sign your name on the line to indicate you want to
participate.
Yes, I understand and want to be in the study or
Signature of Child:
No, I do not want to be in the study.
Date:
Signature of PI or Person Obtaining Assent/Consent:
Printed name of PI or Person Obtaining Assent and Title/Role:
Date:
Consent of Parent or Guardian
I agree with how assent was requested and given by my child and agree to have my child participate in the
study.
Although my child could not give his/her assent, I agree to have my child participate in the study.
I understand that I will be given a signed copy of this Assent/Consent Form to keep.
SIGNATURES
1. Printed Name of Parent/Guardian:
Relationship to child:
Signature:
2. Printed Name of Parent/Guardian:
Relationship to child:
Signature:
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Date:
Date: