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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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