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This sample is a template from which an assent letter can be developed. The language does not have to be repeated verbatim. THE ASSENT FORM SHOULD BE WRITTEN IN TERMS UNDERSTANDABLE TO THE CHILD (avoid or define technical terminology, adjust for educational background and ages, provide translations in other languages when subjects do not understand English). Information provided in italics needs to be filled in and the italics deleted.

NOTE: This template may also be revised for use as a verbal assent script. If the document will be used for this purpose, the language will need to be updated to remove any reference to signing the form. Also, the signature space will need to be deleted.

I am interested in [provide simple description of purpose of research], and I'd like you to help me. I'd like you to [describe activities]. All you'll have to do is [describe child’s participation in activities]. It will take [describe frequency and duration], but you can rest as much as you'd like, and you can stop the whenever you want.

If you want to rest, or stop completely, just tell me--you won't get into any trouble! In fact, if you don't want to [describe activity e.g., play the game, talk to me, etc.], you don't have to. Just say so. Also, if you have any questions about what you'll be doing, or if you can't decide whether to do it or not; just ask me if there is anything you'd like me to explain.

If you do want to try it, please sign your name on the line below. Your parent(s) have already told me that it is all right with them if you want to [describe activity e.g., play the game, talk to me, etc.]. Remember, you don't have to, and once you start you can rest or stop whenever you like.

Sign Your Name:____________________________________________ Date:______________________