Hello and thank you for accessing this form from the University of
Maryland, Baltimore County Institutional Review Board web site.
Prior to submitting, please ensure that spelling and grammar are
correct; this will assist in the timely review of this form during the
IRB evaluation process.
Further instruction on the use of this form and guidance about
submission may be found on the Consent and Assent Guidelines link.
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Whom to Contact about this study:
Principal Investigator:
Department:
Telephone number:
Title of Project:
Participant’s name: _____________________________________________________
MINOR’S ASSENT FORM FOR PARTICIPATION IN RESEARCH ACTIVITIES
(ages 7-18 years)
We are asking you to be in a research study. This form will tell you all about the study and help you
decide to be or not to be in the study. Read this paper carefully and ask any questions you have. You
might have questions about what you will do, how long it will take, if anyone will find out how you did.
When we have answered all of your questions, you can decide to be or not to be in the study. This is
called “informed consent.”
What the study is about:
What I’m being asked to do:
Risks and Benefits:
Prizes:
Privacy:
If you participate in this study, we will not tell anyone else how you did. We will keep all information
about your participation in a locked cabinet without your name on it so that only we can see how you
did. We will use this information to write a big paper on __________. Your name will not be used in
that paper. After we write the paper we will throw away all of this information.
Your Rights



You have the right to carefully read this paper and ask questions before deciding to be or not to be in
the study.
You have the right to choose not to be in the study and nobody will be mad at you.
You have the right to stop participating anytime you want, and you will still get the prize.
If You Have Questions
If you have any questions about the study, call (PI name) at (PI’s phone number).
If you have any questions about your rights, or are upset in any way about the study, you can call
someone in the Office for Research Protections and Compliance at (410) 455-2737.
Signing this paper means that you have read this or had it read to you and that you want to be in
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the study. If you don’t want to be in the study, don’t sign the paper. Remember, being in the
study is up to you, and no one will be mad if you don’t sign this paper or even if you change
your mind later.
-------------------------------------------------------------------------------------------------------------If you want to be in our study, sign your name here:
Name:
Date:
-------------------------------------------------------------------------------------------------------------Investigator’s Statement and Signature:
1) Research for which there is no direct benefit to the child. When there is no direct benefit likely from participation in the
research and the child is old enough to and capable of giving assent, obtaining assent is mandatory. The following
documentation is to be included in the assent form:
The undersigned investigator hereby certifies that he/she has discussed the research project with the child participant and has
explained the information contained in this document, including the reason for the research, the risks, and the benefits or
potential benefits. The undersigned investigator further certifies that the participant was encouraged to ask questions and that
all questions were answered.
Signature _____________________ Date __________
2) Research involving a direct benefit to subject. When there is a direct benefit or potential direct benefit, assent should be
solicited, but obtaining it is not mandatory. Use the following documentation:
The undersigned investigator hereby certifies that he/she has discussed the research project with the child participant and has
explained the information contained in this document, including the reason for the research, the risks, and the benefits or
potential benefits. The undersigned investigator further certifies that the participant was encouraged to ask questions and that
all questions were answered.
Signature _____________________ Date __________
-------------------------------------------------------------------------------------------------------------The child is less than age seven or unable to understand the research:
I/we (parent(s) or guardian)_____________________ waive my/our child's assent and take full responsibility for providing
permission for participation in this research study.
Signature _____________________ Date __________
Signature _____________________ Date __________
(sample assent form) – 03/01/2012
compliance@umbc.ediu
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