ࡱ> ^`] !bjbj BHggc;  8l`49Z(8888888$t;*>888^8846pA沏Bc58809}5^>*>466">688 9> X n: Research Study Assent Form (15-17 Year Age Range) Name of Minor: _____________________________ Parental Permission on File: ( Yes ( No** **(If No, do not proceed with assent or research procedures.) Study Title: [Title as listed on IRB application] Researchers: List names and contact information of investigators and co-investigators My name is (insert the name of the person who will approach the child during the assent process). I am from ͷ. I and the other people listed at the top of this form are inviting you to take part in a research study. Your parent(s) know we are talking with you about the study, but it is up to you to decide if you want to be in the study. This form will tell you about the study to help you decide whether or not you want to take part in it. Why is this study being done? The purpose of the study is to help us learn about (topic or very brief description of the purpose of the study in age appropriate language; should not be above the 8th grade reading level) You are being asked to take part because [include a reason why the subject is being asked to participate (e.g., you are a member of a support group for families of persons with a chronic illness)}. You cannot take part in this study if [list exclusion criteria [(e.g., you are under 18, are taking anti-depressants, you are involved in any other research study at this time, etc).] What am I being asked to do? If you decide to be in the study, we will ask you to (describe what the child will be asked to do in language that is appropriate to the childs age and maturity) Provide a complete description of procedures, including: Each specific step involved and the chronological order in which they occur The estimated amount of time each will take, and the total time involved A description of questionnaires, surveys, and interviews and include examples of the most personal or sensitive information you will be seeking An explanation that the child doesnt have to answer any question they dont want to answer in any test, questionnaire, or interview A description of the use of medical, academic or other records An explanation of any results that will be given to the child or any other person or institutions. If media recording is to be part of the study, explain that here and let the child know that you wont record them without their permission. What are the benefits to me for taking part in the study? Describe potential benefits to the child, if any and those to society. Example: If you take part in this study, you might learn how to make nutritious snacks you like and ways to become more physically fit. Note: Do not include financial compensation, course credit, or other forms of incentive as benefits of being in the project. This information belongs in the section on costs or payments. Are there any risks to me if I am in this study? The potential risks of taking part in this study are: In addition to physical risks/discomforts or stress, describe any other risks, such as: psychological, economic, social, employment, reputation, or loss of confidentiality or sensitive information. Include risks associated with sensitive questions, for example, distress or discomfort. If applicable, include risks of reporting illegal or reportable behavior (abuse or intent to harm). Describe the precautions that are being taken to minimize risks and steps that will be taken if risks occur. If applicable, discuss the availability of referrals, counseling, or other services, such as suicide counseling. Note: Do not state that there are no risks or that risks should be minimal. Will my information be kept private? The data for this study will be kept private and confidential to the extent allowed by federal and state law. Under rare circumstances your data you may be reviewed by WSU officials or people from the organization or agency that funded the study. If data are coded and a key maintained separately, inform participant of the process. Explain how you will maintain the participants privacy throughout the study (e.g. private conversations, interaction with other participants) If applicable, discuss required reporting (e.g., potential suicide or homicide, child abuse). Describe where data will be stored and how it will be protected. Describe who will have access to the data, including: All researchers and research staff Institutional Review Board (IRB) Sponsors, agencies Inform participants if voice, video, digital or image recordings will be made of them, and indicated if this is required to be in the study. If not required, a separate check box must be included with the signature at the end of the form. When we tell other people or write articles about what we learned in the study, we wont include your name or that of anyone else who took part in the study. Compensation (If applicable) You will receive _____ for taking part in this study. If you decide to stop taking part in the study you will receive _____. (Explain the method or schedule for each payment.) [or] You will not receive money or any other form of compensation for taking part in this study. What are my rights as a research study volunteer? Your participation in this research study is completely voluntary. You do not have to be a part of this study if you dont want to. There will be no penalty to you if you choose not to take part and no one will be upset or angry at you. You may choose not to answer any questions you dont want to answer, and you can change your mind and not be in the study at any time. Who can I talk to if I have questions? If you have questions at any time, you can ask the researchers and you can talk to your parent about the study. We will give you a copy of this form to keep. If you want to ask us questions about the study, call or email (name of contact person) (local phone number and email address) If you have questions about your rights in the study, or you are unhappy about something that happens to you in the study, you can contact the ͷ IRB Office at irb@kennesaw.edu. Statement of Consent If you want to participate in this research, please sign below. 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