Assent Form - Example printable pdf download

Assent Form - Example

ASSENT FORM: EXAMPLE 1

STUDY DETAILS:

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ASSENT TYPE: STANDARD WRITTEN

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LOCATION: ELEMENTARY SCHOOL CLASSROOM

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PARTICIPANT POPULATION: SUBJECTS AGED 7-18 YEARS

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COMPENSATION: NONE

FOR REFERENCE ONLY – DO NOT COPY VERBATIM

CONTENT OF THE ASSENT FORM MUST BE MODIFIED AND MADE

APPLICABLE TO THE SPECIFIC STUDY

ASSENT TO PARTICIPATE IN RESEARCH STUDY

PRINCIPAL INVESTIGATOR: James Kirk, Ph.D.

CONTACT DETAILS:

Room 664

Psychology Department

490 Boston Ave

Medford, MA 02144

Tel: (617) 627-5555

Email:

mary.brown@tufts.edu

What is this study about? I am a teacher at a college and I want to understand how students

learn about history. We are going to try to do this by asking you a few questions about your

history class and how it is taught. We want to know what you think makes learning about

science fun and interesting.

What will you do in the study? First we will ask your teacher for permission to come to your

class. Then we will ask you to take an assessment, which is like a test, but isn’t a school test. It

will not change your grade in school and no one will see your answers except me, not even your

teacher. The assessment will ask you about what happens in your history class and what things

you like or don’t like. This is how we can understand what you think makes learning about

history fun and interesting. This assessment will take about 30 minutes for you to complete.

How will my privacy be protected? When you take the assessment, you will not have to write

your name on it. Also, only I will see your answers, not your teacher or anyone else at the

school. After we look at your answers and your classmates’ answers, we might publish them in

Revised 12/2011

Assent Form - Example