SAMPLE ASSENT FORM, SCHOOL-BASED STUDY (with Use of Media Records)
UNIVERSITY OF CALIFORNIA AT BERKELEY
BERKELEY  DAVIS  IRVINE  LOS ANGELES  MERCED  RIVERSIDE  SAN DIEGO  SAN FRANCISCO
SANTA BARBARA
 SANTA CRUZ
INFORMATION ABOUT A RESEARCH STUDY
Title of Study (7–12 Year Olds)
My name is __________. I am a student in the School of Education at U.C. Berkeley. I am
working with my professor, __________, on a research study. We are asking you to be part of it.
A research study is when people like me collect a lot of information about a certain thing to find
out more about it. This letter tells you about my study so you can decide if you want to be in it.
Before you decide, you can talk about it with your parents or anyone else you like.
We are doing this study to find out more about how kids learn when they do math on a computer.
We’re inviting you to take part because you go to a school where we’re doing the study.
If you agree to be in the study and your parents say it’s okay, we will ask you to:
 Play a computer game that has math problems. This will take about a half hour (30 minutes).
 Have an interview where I ask you about how you study and learn. I will audiotape (record
what we're saying) if you give permission. This will take about a half hour (30 minutes).
 Let us videotape you in your math class. If you agree, we will videotape during your regular
math class once or twice a week for 3 weeks. We won't interrupt the class.
Place and total time: The computer game and interview will be done in [location] and will take
about an hour (60 minutes) altogether. The videotaping will be done during your regular math
class, so it won't take any extra time.
If you don’t want to be in the study, your teacher will give you a different activity to work on.
[brief description]. It will take about the same amount of time as the research activity.
Any benefits? Being in this study won’t change anything for you. But we hope that what we
find out from this research help kids in the future to learn math on a computer.
Any discomforts? You might get bored or tired and decide that you don’t want to finish the
computer game or interview. If this happens, just tell us you want to stop.
Who will know? If we write up a report or give talks about this research, we won't use any real
names of people who were in it. We will just talk about what we learned from all the results put
together. But if you and your parents give us permission to record and play the audiotapes or
videotapes later, there's a chance someone could recognize you. The next page asks about this.
Do you have to participate? No, research is something you do only if you want to. Whether you
decide to participate or not, it will have no effect on your grades at school. And if you agree, you
can always change your mind later if you don't want to be in the study any more.
Questions?: You can ask questions about this study at any time, now or later. Feel free to contact
me, [PI/SI's name], at 510-000-0000 or email@xxxx.xxx. Or you can contact U.C. Berkeley's
Committee for the Protection of Human Subjects at 510-642-7461 or subjects@berkeley.edu.
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STUDENT ASSENT (7-12 years old)
If you decide to participate, and your parents agree, we will give you a copy of this form to keep.
That way you can look at it later if you want to.
If you would like to be in this research study, please sign your name on the line below.
________________________________________
Child's Name/Signature (printed or written by child)
_______________
Date
________________________________________
Signature of Investigator/Person Obtaining Assent
_______________
Date
******************************************
PERMISSION FOR TAPE RECORDINGS [/OTHER RESEARCH RECORDS]
1. Researchers may audiotape me during the interview.
Yes___ No___
2. Researchers may include me in the classroom videotapes they make.
Yes___ No___
3. Researchers may use the tapes to help teachers learn.
Audiotapes: Yes___ No___
Videotapes: Yes___ No___
4. Researchers may use the tapes to help other people learn.
Audiotapes: Yes___ No___
Videotapes: Yes___ No___
5. Researchers may share the tapes with other researchers.
Audiotapes: Yes___ No___
Videotapes: Yes___ No___
________________________________________
Child's Name/Signature (printed or written by child)
_______________
Date
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