ࡱ> Y[X Lbjbj H$WNN8$,RDD(lll6!6!6!QQQQQQQ$TEWvQ6!!"6!6!6!QllQ%%%6!RllQ%6!Q%%FLNP l`.4<!jOTrQQ0ROTW!WZPZPWnP6!6!%6!6!6!6!6!QQ#6!6!6!R6!6!6!6!W6!6!6!6!6!6!6!6!6!N n: [Please remove this text and add content as needed.] SAMPLE ASSENT FORM UNIVERSITY OF WASHINGTON ASSENT TO RESEARCH STUDY OF ______________ Researchers: [LIST NAMES, POSITIONS, DEPARTMENTAL AFFILIATIONS, AND TELEPHONE NUMBERS OF LEAD RESEARCHER AND CONTACT PERSON FOR SUBJECTS] Researchers statement: My name is [identify yourself to the child by name]. We are asking you to be in a research study because we are trying to learn more about [outline what the study is about in language that is appropriate to both the childs maturity and age]. If you agree to be in this study [describe what will take place from the childs point of view in language that is appropriate to both the childs maturity and age]. [Describe any risks to the child that may result from participation in the research.] [Describe any benefits to the child from participation in the research.] Please talk this over with your parents before you decide whether or not to do this. We will also ask your parents if it is okay for you to be in this study. But even if your parents say yes you can still decide not to do this. If you dont want to be in the study, you dont have to participate. Remember, being in this study is up to you and no one will be upset if you dont want to participate or even if you change your mind later and want to stop. You can ask any questions about the study. If you have a question later you can call me [insert your telephone number] or ask me next time. [If applicable: you may call me at any time to ask questions about your disease or treatment.] Signing your name at the bottom means that you agree to be in this study. [If the study is related to treatment insert the following: Your doctors will continue to treat you whether or not you participate in this study.] You and your parents will be given a copy of this form after you have signed it. _________________________________________________________ _________________ Researchers signatureDateYour statement: This research has been explained to me. I agree to take part in this study. I have had a chance to ask questions. If I have more questions, I can ask the doctor or researcher. _______________________________________________ _______________ Your signatureDate Copies to: Subject Researchers file     Sample Assent Form (01/30/2015) PAGE 1 of  NUMPAGES 2 3456HIitu  - / y ˼~qdVI<hphEMOJQJ^JhphOJQJ^Jhph>*OJQJ^Jhph,OJQJ^JhphZOJQJ^JhphO OJQJ^J#hphEM5CJOJQJ^JaJ#hph[5CJOJQJ^JaJhph[OJQJ^Jhph[0JOJQJ^J/jhph5OJQJU^JmHnHuhphi5OJQJ^Jhphe5OJQJ^J5Ibu / d "  g M / H $Ifgd[(gdR(gd[(gdEM($a$gdEM($a$gdR$a$gdRy ~ ! 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