Short Form Assent English OLD - Seattle Children's



THIS DOCUMENT MUST BE IN YOUR LANGUAGE

SHORT FORM ASSENT

Assent to Participate in Research – Short Form

Introduction

We are asking you to be in a research study. Research is a way to test new ideas. Research helps us learn new ways to take care of kids.

Being in a research study is your choice. You can say Yes or No. Whatever you decide is OK. We will still take good care of you.

The people doing the research study are called researchers. The researchers will tell you about the research study. This information will help you decide if you want to be in the research study.

WHY is the research study being done?

The researchers will tell you why the research study is being done. They will also explain what they hope to learn in this study.

WHAT will happen in the research?

The researchers will tell you:

• How long the study will last

• What kinds of things you will have to do if you take part

• How long all these things will take

What are the BAD things that can happen?

The researchers will tell you what bad things can happen if you take part in the research study. They will tell you about things that might hurt, or make you scared or embarrassed. They will also explain what they can do to make these things less bad.

What are the GOOD things that can happen?

The researcher will tell you what good things can happen if you take part in the research study. They will tell you if being in the research study might help you. Sometimes the research won’t help you but may help other children in the future.

What if you don’t want to take part? What if you want to stop?

Being in the research is your choice. It is OK to say No. No one will be mad at you.

If you say Yes and change your mind later on, that’s OK. You can stop being in the research at any time. Tell the researcher if you want to stop.

What if you want to take part?

If you decide you want to be in the research study you will meet with a researcher. This researcher, with the help of someone who speaks your language, will tell you about the research study. Tell the researcher if you decide you want to be in the study.

Take the time you need to make your choice. Ask the researcher any questions you have. You can ask questions anytime.

PLEASE NOTE: If you want to be in the research study, the researcher will give you a form written in your language. That form will explain the research study. They will give it to you when it is ready.

Participant’s Statement

The researcher told me about the research study. I had a chance to ask questions. I know I can ask questions at any time. I want to be in the research study.

_________________________________________________

Printed Name of Research Participant

________________________________________________________________________

Signature of Research Participant Date

_________________________________________________

Printed Name of Parent or Legal Guardian

________________________________________________________________________

Signature of Parent or Legal Guardian

___________ _____________

Date Time

Witness Information

PLEASE NOTE: A witness name and signature is required when using the Short Form Assent to document assent.

Witness Statement

I have been present during the oral presentation of this research study.

________________________________________________________________________

Printed Name of Witness

________________________________________________________________________

Signature of Witness

___________ _____________

Date Time

Copies to: Research Participant or Parent(s)/Legal Guardian

Medical Records (if appropriate)

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