Assent Form – Ages 6-15 years

Assent Form – Ages 6-15 years

Medical & Scientific Research to Help the nation and world live better

EMPOWER-1 Research Study


    This form documents that Assent has been given by a child and that a person(s) with parental responsibility has agreed to the child’s participation in the Empower-1 Research Study. “Section A” confirms whether assent is in place. “Section B” documents Assent from the child and a person with parental responsibility.

    Participants Name

    Persons with Parental Responsibility


    PLEASE SELECT THE OPTION TO SHOW US YOUR CHOICE

    1. Have you read (or your Doctor or Nurse read to you) the Participation Information Booklet?

    2. Did that information make sense to you?

    3. Do you understand the reason for doing this Research Study?

    4. Have all your questions about the Research Study been answered in a way that makes sense?

    5. Do you know that only you will decide if you want to take part in this Research Study?

    6. Are you happy to join this Research Study?

    Thank you for helping us by answering these questions.
    If you said no to any of the questions then you will not have to take part in this study.
    If there are any new questions, you can ask them now. If you have new questions later, you can ask your parents, family, Doctor or Nurse.


    To take part in the Research Study, please let us know by filling out the section below. Your parent(s) or guardian will also sign to confirm that you have agreed to join the Study.

    Child's Name

    Date of Birth (DD/MM/YYYY)

    Date (DD/MM/YYYY)

    Mother's Name*

    *Only a single adult with parental responsibility needs to sign this form to allow for Database participation,
    although additional person(s) may also sign.

    Signature

    Date (DD/MM/YYYY)

    Father's Name

    Signature

    Date (DD/MM/YYYY)

    Guardian's Name

    Signature

    Date (DD/MM/YYYY)

    Name of Researcher that obtained Consent

    Signature

    Date (DD/MM/YYYY)

    Congratulations, you are now part of the Empower®-1 Research Study.

    You will receive a copy of this completed form.
    This original completed form will be stored by the researcher as part of the Empower®-1 Research Study Records. Additional copies will be given to your parent(s) or guardian, and your Doctor.
    You can either have a hard copy of the form or receive a copy via email. Please let the Researcher know your preference.

    Thank you again,

    The Research Team from the Empower®-1 Study.

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