Sample IRB Child Assent Form


[Note: The sample "Child Assent Form" is to be used only in research projects where children or youth under the age of 18 are identified participants. Research conducted with adult participants (over the age of 18) would employ the "Informed Consent Form" only (please see the sample "Informed Consent Form" on the PHE Web page under "IRB, Sample Informed Consent Form"). Researchers are cautioned that in some instances, both the Informed Consent Form and the Child Assent Form may be required for a single project. Questions regarding the appropriate use of consent forms should be forwarded to the Chair of the Institutional Research Board at (864) 597-4642.]

Assent for Participation in the

Child and Adolescent Depression Project

Principal Investigator: I. Bee Student
Telephone Number: (555) 401-4011
Faculty Sponsor: I. B. Prof, EdD
Telephone Number: (555) 450-0455
Department: Department of Education
Institutional Review Board Telephone Number:  (864) 597-4642

We want to find the best way to help children like you feel good about life and themselves and succeed at home, in school, and with their friends.

First, we will work with you to find out what makes you feel unhappy and what is hard for you. Then you will be with a therapist alone or with other children like yourself learning how to feel better, relax, get along with others, and solve problems on your own. Second, we will also work with your parents to find ways they can help you succeed at home and at school. You and your parents will come to these meetings until you start to feel better most of the time. Finally, three months and six months after you finish the sessions we will speak with you to see how you are doing. A worker will explain anything to you or answer any questions. Please understand you may leave the program at any time. No one else will know any of your answers to any of the questions, because your name will not be used.


Your name below means that it is "OK" with you to be in the program.

Child's Signature: ____________________________  Date: _____________________

Witness's Signature:___________________________ Date: _____________________


I have read the preceding and I give consent for my child to participate in this research project. A copy of this form has been given to me.

Parent or Legal Guardian's

Signature:___________________________________ Date:_____________________

Witness's Signature:___________________________ Date:_____________________

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