ࡱ > S U T E 4 bjbj 46 hj ihj i N 4 4 4 4 4 H H H 8 L $ H , ( L > K, M, M, M, M, M, M, $ / `2 q, 9 4 L L q, 4 4 4 , F 4 4 K, K, ) | * B * 7, , 0 , * 3 ~ 3 $ * * 8 3 4 + $ q, q, 0 , 3 X : THIS IS AN ASSENT TEMPLATE FOR A CHILD/YOUTH AGE 1317 TO AGREE TO PARTICIPATE IN A RESEARCH STUDY. PLEASE FEEL FREE TO REVISE THIS TEMPLATE TO BETTER FIT YOUR PROPOSED RESEARCH. USE A 12 POINT FONT AND GENEROUS PARAGRAPH BREAKS TO FORMAT. THE TEXT IN RED IS FOR GUIDANCE. DELETE OR REPLACE RED TEXT BEFORE SUBMITTING THE FINAL VERSION WITH THE IRB APPLICATION. THE FINAL VERSION SHOULD NOT HAVE ANY RED TEXT. California State University, Long Beach (ɫɫ) SAMPLE ASSENT FORM FOR CHILDREN 13 TO 17 YEARS AFTER PARENTAL/GUARDIAN PERMISSION IS OBTAINED [INSERT STUDY TITLE] ASSENT TO BE IN A RESEARCH STUDY For Youth 13-17 years old What is this study about? My name is [PI name(s) from department/college] at ɫɫ, and I am doing a research study. The study is a survey of [Approximate number] youth who are age [Indicate age range for study] about [Describe research topic]. I am asking you to take part in the study because you [Describe eligibility criteria]. I hope the answers from the people who complete the survey will help me better understand [Describe research topic]. What will happen if you decide you want to be in this research study? Your parent/guardian gave their permission for me to ask you to be in the study. If your parent/guardian did not give their permission, you cannot be in the study. What will you have to do for the study? You will [Describe study procedures, duration of the study, any applicable options such as skipping question items, taking breaks, any direct benefits, indirect benefits, whether video or audio recording is optional or required, etc.]. [If school-based study include the statement: Whether you decide to participate or not will have no effect on your grades at school.] Is there anything bad that could happen to me? [Describe any possible risks and risk mitigations if applicable] Your participation is voluntary. What if you have questions? You can always ask me or the other researchers any questions you might have about the study. You can ask your questions now or later, any time you like. You can also have your parent/guardian ask me or other researchers questions for you. What are your choices? Your parent/guardian agreed that you can be in this study. But you dont have to be in the study if you dont want to. It is alright not to be in the study. Nobody will get mad at you if you dont want to do this. If decide not to be in the study now or if you start the study and then decide to stop participating, nothing bad will happen to you. If you decide to be in the study now and you change your mind later, thats okay, too. You just have to tell me, or the other researchers or tell your parent/guardian when you change your mind, and you will be taken out of the study. You can always have your parent/guardian talk to me, [PI name] [If applicable, my faculty advisor, name] at any time during the study. Your parent/guardian can contact me at [phone#] or [email] Your parent/guardian can contact [my faculty advisor, name] at [phone#] or [email] If you have any questions or concerns about your rights as a research participant, you may have your parent/guardian contact the ɫɫ Institutional Review Board (IRB) at 562-985-8147 or IRB@csulb.edu. An IRB is a committee that reviews research to ensure that the rights and welfare of research participants are protected. ** If you want to be in this study, please sign your name below. If you sign below, it means you agree to participate in this study. If you dont want to be in t h i s s t u d y , j u s t t e l l m e a n d d o n t s i g n t h i s f o r m . I w i l l g i v e y o u a c o p y o f t h i s f o r m t o k e e p . & I g i v e a s s e n t t o b e [ c h o o s e r e l e v a n t m e d i a a u d i o , v i d e o , z o o m , e t c . ] r e c o r d e d . & I d o N O T g i v e a s s e n t t o b e [ c h o o s e r e l e v a n t m e d i a a u d i o , v i d e o , z o o m , e t c.] recorded, but give assent to the researcher taking notes. __________________________________ _______________ _____ Youth's Signature Date Age __________________________________ Print Youth's Name ___________________________________________ _______________ Signature of Person Conducting Assent Discussion Date ___________________________________________ Print Name of Person Conducting Assent Discussion Version: 10 Nov 2023 Page PAGE 2 OF ! & , 0 1 3 4 5 6 7 ? @ R T \ b - ? @ R T j k l ~ 볟 2h] h] 56B*CJ OJ QJ ]^J aJ ph 'h] h] 5CJ OJ PJ QJ ^J aJ hQ hQ OJ PJ QJ \^J +hQ hQ 5>*B*OJ PJ QJ ^J ph "hQ 5B*OJ PJ QJ ^J ph (hQ hQ 5B*OJ PJ QJ ^J ph 3 . / $a$gd] I $$ z ( `p 0@P ` !p# %&(0*+-@/02P4 67`9;
@A @&