Assent Form: 11-15 years – INVOLVE

Assent Form: 11-15 years – INVOLVE

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 INVOLVE Research Database. “Section A” confirms whether assent is in place. “Section B” documents Assent from the child and a person with parental responsibility.

 

Details
Participants Name  
Person(s) with

Parental Responsibility

 

 

 

Section A

  1. Have you read (or your Doctor or Nurse read to you) the Participation Information Booklet? (Yes/No)
  2. Did that information make sense to you? (Yes/No)
  3. Do you understand the reason for doing this Research Database? (Yes/No)
  4. Have all your questions about the Research Database been answered in a way that makes sense? (Yes/No)
  5. Do you know that only you will decide if you want to take part in this Research Database? (Yes/No)
  6. Are you happy to join this Research Database? (Yes/No)

 

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 Research Database.

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.

 

Section B

To take part in the Research Database, 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 Research Database.

 

Child’s Name (BLOCK CAPITALS)
Date of Birth (DD/MM/YYYY)
Date (DD/MM/YYYY)
Signature
Date (DD/MM/YYYY)

 

*Father’s Name (BLOCK CAPITALS)
Signature
Date (DD/MM/YYYY)

 

Signature
Date (DD/MM/YYYY)

 

Name of Researcher that obtained Consent (BLOCK CAPITALS)
Signature
Date (DD/MM/YYYY)

 

*Guardian’s Name (BLOCK CAPITALS)
*Mother’s Name (BLOCK CAPITALS)

 

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

 

Congratulations, you are now part of the INVOLVE Research Database.

You will receive a copy of this completed form.

This original completed form will be stored by the researcher as part of the INVOLVE Research Database 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 INVOLVE Research Database.