[Insert title of the study using 15 point bold type.]

1. My name is [identify yourself to the child by name] from DePaul University.

2. We are asking you to take part in a research study because we are trying to learn more about [outline what the study is about in language that is both appropriate to the child’s maturity and age. State the reason why the individual is being asked to participate. If the study involves a questionnaire, briefly describe the type of questions asked. State the time commitment for the individual. (See IRB Policies and Procedures Handbook for some examples of different types of information included on Informed Assent Forms.)].

3. If you agree to be in this study [describe what will take place from the child’s point of view in language that is both appropriate to the child’s maturity and age].

4. [Describe the risks, if any, to the child that may result from participation in the research. State the actions taken to minimize risk and describe how confidentiality or anonymity will be maintained. (See IRB Policies and Procedures Handbook for some examples of how risks may be described and for statements that must be included for studies that present greater than minimal risk or that may uncover suspected child abuse or neglect.)]

5. [Describe the benefits, if any, to the child from participation in the research. If there are no benefits to the child, indicate that and perhaps describe the general value of the study. (See IRB Policies and Procedures Handbook for some example statements.)]

6. We have asked your parents to give their permission for you to take part in this study. But even if your parents have said "yes" you can still decide not to do this. We hope that you have talked this over with your parents before deciding whether or not to participate.

7. If you don’t want to be in this study, you don’t have to participate. Remember, being in this study is up to you and no one will be upset if you don’t want to participate. Even if you change your mind later and want to stop you may withdraw your agreement to particpate without any consequences.

8. You can ask any questions that you have about the study. If you have a question later that you did not think of now, you can call me [insert your telephone number], ask me next time, or you may speak to the Coordinator of the DePaul University Institutional Review Board for the Protection of Research Participants by calling (773) 325-2593.

9. Signing your name at the bottom means that you agree to be in this study. You and your parents will be given a copy of this form after you have signed it.

Name of Participant __________________            Date ___

Signature________________________ Age____ Grade in School______

DPU-IRB approval number __________