Example Format of an Assent Document

3rd Grade Reading Level

(Recommended Font ? Comic Sans)

University at Buffalo
Assent to be in a Research Study

TITLE OF STUDY

Who are we?

"My name is __________ and I am a ___________ at the University of Buffalo (or other location). I work in the Department of _________________."
Why are we meeting with you?

"We want to tell you about a study that involves children like yourself. We want to see if you would like to be in this study too."
Why are we doing this study?

Briefly describe in simple words why you are doing the study and what you hope to find out.
What will happen to you if you are in the study?

Describe in simple words, step by step, the procedures the child will undergo and state how long they will be in the study.
What are the good things and bad things that may happen to you if you are in the study?

Describe in simple words any benefits or risks associated with the study. If none, it should be stated there are none.
Do you have to be in the study?

"No you don?t. No one will get angry or upset with you if you don?t want to do this. Just tell us if you don?t want to be in the study. And remember, you can change your mind later if you decide you don?t want to be in the study anymore."
Do you have any questions?

"You can ask questions at any time. You can ask now. You can ask later. You can talk to me or you can talk to someone else at any time during the study. Here are the telephone number to reach us:"

If you want to be in the study, sign your name on the line below: