ASSENT DOCUMENT

Project:
Investigator(s):

I am doing a research study. A research study is a special way to find out about something . I am trying
to find out

If you decide that you want to be in this study, I will ask you to do several things.

I want to tell you about some things that might happen to you if you are in this study,

Not everyone who is in this study will benefit. A benefit means that something good happen to you. I
don’t know if you will benefit. But i hope to learn something that will help other people some day.

When I am done with the study, I will write a report about what I found out.. I won’t use your name in
the report.

You do not have to be in this sturdy. It is up to you. If you say okay now, but you want to stop later, that
is okay too. All you have to do is tell me.

If you want to be in this study, please sign your name.

1.____________________________________, want to be in this research study.

(Print your name here)

_____________________________________ ________________
(Sign your name here) (Date)

______________________________________ ________________

(Signature of Parent or Guardian) (Date)

By signing, you are stating that you are willing to participate in this study and that you have received a
copy of the consent form.