Assent form for adolescents

SAMPLE ASSENT FORM FOR USE BY INVESTIGATORS

Name of Study: _________________________________________
____________________________________________________

I understand that I have been asked to participate in a study about________________________________________________
_______________. I will be asked to___________________________________
____________________________________, which will take about______minutes.
I understand that I do not have to participate. If I do participate, I can quit at any time. I
also understand that I do not have to answer any questions I don’t want to answer or do
anything I don’t want to do.

My parents, teachers, or anyone else will not know what I have said or done in the study.
No one but the researcher will know.

This study is being done by_____________________________ (Name of researcher)
at St. Joseph’s College. His/her phone number is___________________.

If I have any questions or concerns about the study, I can call and ask him/her about
them.

When I sign my name, this means that I agree to participate in the study and that all of
my questions have been answered. I have also been given a copy of this form.

Name____________________________ Signature_______________________
Name of Witness _______________________
Witness Signature_______________________ Date____________________

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