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Sample Parental Permission/Minor Assent for Participants old enough or capable to assent – Use information from your protocol to write this document. Use language that will be understood by your target population. Add “Page 1 of ___”, etc. Add “Parent/Guardian initials _____” and “Participant initials_____” at the bottom of each non-signature page. Explanatory information is on the left.

|Print your document on your |LETTERHEAD |

|dept.’s letterhead | |

| |(NOTE: DO NOT AGREE TO PARTICIPATE UNLESS AN APPROVAL STAMP WITH CURRENT DATES HAS BEEN APPLIED TO THIS DOCUMENT.) |

|Add this statement. | |

| |PARENTAL PERMISSION/CHILD ASSENT |

|Use this heading |for a Research Study entitled |

| |“Title of Your Study” |

| | |

|Invite; describe purpose |Your son or daughter is invited to participate in a research study to ____ (purpose and objectives)___. The study is |

|(Protocol section 9) and |being conducted by (your name, title), under the direction of __(advisor, title)__ in the Auburn University Department |

|inclusion criteria (Protocol |of _________. Your son or daughter is invited to participate because he or she is ________________. Since he/she is |

|section 12) |age 18 or younger we must have your permission to include him/her in the study. |

| |What will be involved if your son/daughter participates? If you decide to allow him/her to participate in this |

|Briefly explain what will occur |research study, he/she will be asked to ______________. Your son’s/daughter’s total time commitment will be |

|during the study (from Protocol |approximately _____________. |

|section 13b) | |

| |Are there any risks or discomforts? The risks associated with participating in this study are ____________. To |

|Describe any foreseeable risks or|minimize these risks, we will _________. (If medical treatment may be necessary, add the following:) You are |

|discomforts and how they will be |responsible for any costs associated with medical treatment for your son or daughter. |

|minimized | |

|(Protocol sections 14 & 15) | |

| |Are there any benefits to your son/daughter or others? If he/she participates in this study, he/she can expect to |

|Use information from Protocol |________________. We/I cannot promise you that your son/daughter will receive any or all of the benefits described. |

|section 16 | |

| | |

|Information from Protocol section|Will there be compensation for participating? To thank your son or daughter for participating, __________ will be |

|12e |offered. |

| | |

|Use information from the |Are there any costs? If you decide to allow your son/daughter to participate, you will ____________. |

|protocol, if applicable | |

| | |

|Add initial lines. | |

|Add page numbering |Parent/Guardian Initials______ |

| |Participant Initials_______ |

| | |

| |If you (or your son/daughter) change your mind about his/her participation, he/she can be withdrawn from the study at |

|If you will provide partial |any time. His/her participation is completely voluntary. If you choose to withdraw your son/daughter, his/her data can|

|compensation after participant |be withdrawn as long as it is identifiable. Your decision about whether or not to allow your son/daughter to |

|withdraws, include here (section |participate or to stop participating will not jeopardize your or his/her future relations with Auburn University, the |

|12e) |Department of _____________ or _________________. |

| |Your son’s/daughter’s privacy will be protected. Any information obtained in connection with this study will remain |

|Describe whether the data is |anonymous or confidential. The data collected will be protected by ___________. Information obtained through his/her |

|anonymous or confidential, how it|participation may be___________ (e.g. used to fulfill an educational requirement, published in a professional journal, |

|will be protected and the extent |presented at a professional meeting, etc….) |

|to which it will be maintained. | |

|Include other info- (alternative | |

|procedures, investigator’s right | |

|to terminate study…) | |

|Include investigator’s & |If you (or your son/daughter) have questions about this study, please ask them now or contact ___________________ at |

|advisor’s contact info |_____________________ or _________________ at ___________________. A copy of this document will be given to you to |

|(If you have to print to >1 page,|keep. |

|have this info on the last page) | |

| |If you have questions about your child’s rights as a research participant, you may contact the Auburn University Office |

|You must include this statement |of Research Compliance or the Institutional Review Board by phone (334)-844-5966 or e-mail at IRBadmin@auburn.edu or |

| |IRBChair@auburn.edu. |

| | |

|You must include this statement |HAVING READ THE INFORMATION PROVIDED, YOU MUST DECIDE WHETHER OR NOT YOU WISH FOR YOUR SON OR DAUGHTER TO PARTICIPATE IN|

| |THIS RESEARCH STUDY. YOUR SIGNATURE INDICATES YOUR WILLINGNESS TO ALLOW HIM OR HER TO PARTICIPATE. YOUR |

| |SON’S/DAUGHTER’S SIGNATURE INDICATES HIS/HER WILLINGNESS TO PARTICIPATE. |

|The parent, participant and |_____________________________ ______________________________ |

|investigator sign at the same |Participant's signature Date Investigator obtaining consent Date |

|time. If the participant is too |____________________________ _____________________________ |

|young to understand and sign this|Printed Name Printed Name |

|document, leave off the child’s |________________________________ |

|signature. A separate “Child |Parent/Guardian Signature Date |

|Assent” can be given to minors. |_________________________________ |

| |Printed Name |

| | _________________________________ |

|If applicable, add these lines |Co-Investigator Date |

| |_____________________________ |

| |Printed Name |

| | |

-----------------------

Version Date (date document created): ______________

Allow Space for the AU IRB Stamp

Allow Space for the AU IRB Stamp

Version Date (date document created): ______________

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