ࡱ> 574[ 9bjbj~~ .bbA668",&&&&&$N&&QQQF&&QQQQ& e DGFQ0"QQQ<QQ"6B x: [Title of Study] Assent Form My name is [researcher name]. I am trying to learn about [insert topic of study in simple language] because [explain research purpose in age-appropriate language]. You can be in my study if you would like. If you decide you want to be in my study, you will [explain all tasks and procedures clearly and simply]. [Explain the risks and benefits in clear, simple child-friendly language. The benefits must outweigh the risks] I will put things I learn about you together with things I learn about other [children, teens], so no one can tell what things came from you. When I tell other people about my research, I will not use your name, so no one can tell who I am talking about. No other people, except your parents, will know if you are in my study. Your parents, or whoever takes care of you, have to say its Okay for you to be in the study. After they decide, you get to choose if you want to do it or not. If you dont want to be in the study, no one will be mad at you. If you want to be in the study now and change your mind later, thats Okay too. You can stop being in this study any time. My telephone number is [researchers telephone number]. You can call me if you have questions about the study or if you decide you dont want to be in the study any more. I will give you a copy of this form in case you want to ask questions later. Agreement I have decided to be in the study because I want to. I know that I do not have to do this. [Name of researcher] has answered all my questions. ______________________________ ________________ Name and Signature of Study Participant Date ______________________________ ________________ Name and Signature of Researcher Date [Insert contact information here]     SWAGƵIRB: Child Assent Template 8.17.17 ] ^    Y " H W j u v " # $ % q r s t ~  IJSUtyz ƾh].QhjhUh1!h5h}OJQJh}5CJOJQJ\h@Eh}CJOJQJhEh} h}5\G] ^   v w # % r t ~  Jyz$a$ 23456789  H$!gd].Qgd].Q (*2345689h1!hh].Qh].Qh].Q6 ,1h/ =!"#$% s2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH :@:  Heading 1$@&5\DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 4@4 ].QHeader  H$6/6 ].Q Header CharCJaJ4 @4 ].QFooter  H$6/!6 ].Q Footer CharCJaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w< 9 <>@C 9 9 8@0(  B S  ?7:7:#CVYAHjjJStt ())*1: 1!E].Q_m5}{@E@3;339@UnknownG.[x Times New Roman5Symbol3. .Cx Arial3.[x TimesA$BCambria Math"h rX'JX   !r42HP ?}2!xxщ [Title of Study]Computing ServicesGeiger, Deborah Oh+'0 ( H T `lt|[Title of Study]Computing ServicesNormalGeiger, Deborah3Microsoft Office Word@F#@x@@$D  ՜.+,0 hp  College of St. Catherine  [Title of Study] Title  !"#%&'()*+-./01236Root Entry F D8Data  1TableWordDocument.SummaryInformation($DocumentSummaryInformation8,CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q