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Sample Assent Form

This sample is intended to help you create an assent document; the text here is a suggestion for how to introduce the required elements of an assent form in a way that is easy for a child to understand.  Please refer to the document Assent Tips to see what elements are required in an Assent form.

Sample Minor Assent Document

Project Title:

We are doing a research study about purpose in simple language.  A research study is a way to learn more about people. If you decide that you want to be part of this study, you will be asked to description, including time involved.

There are some things about this study you should know.  These are procedures, things that take a long time, other risks, discomforts, etc.

Not everyone who takes part in this study will benefit.  A benefit means that something good happens to you.  We think these benefits might be description.

If you do not want to be in this research study, we will tell you what other kinds of treatments there are for you. This statement applies to research projects that offer treatment or intervention.

When we are finished with this study we will write a report about what was learned.  This report will not include your name or that you were in the study.

You do not have to be in this study if you do not want to be.  If you decide to stop after we begin, that’s okay too.  Your parents know about the study too.

If you decide you want to be in this study, please sign your name.

I, _________________________________, want to be in this research study.

___________________________________              ______
               (Sign your name here)                                   (Date)

Parts in Italics should be modified for your specific project.  Other parts may need to be modified as well depending on your research methods.