Sample Child Assent Form

Child Assent Form 

IRB #061717-4 

Title of the Research Study:  Assessing the Impact of Speech Rate and Performance in Dysarthric Speakers 

Summary
In this study we will try to learn how changing the speed you talk affects the way you talk.  You might like to participate because you may learn to speak more clearly, but the study will take about an hour.

1. We would like to invite you to take part in this study.  Faculty in the Department of Communications Disorders from the University of Nebraska at Kearney are conducting the study.
2. Please talk this over with your parents before you decide whether or not to participate in this study.  Your parents will also be asked to give their permission for you to take part in this study.  But even if your parents say “yes,” you can still decide not to be in the study.
3. If you have any questions at any time, please ask.
4. In this study we will try to learn more about how changing the speed at which you speak affects the way you and other people speak.
5. Your decision to be in this study is voluntary.  You do not have to participate if you do not want to.
6. If you volunteer to be in this study, we will place a small mask over your nose, but you will be able to breathe without any problem.
7. We will also put a small plastic tube in your mouth.
8. The mask over your nose and the tube in your mouth will not hurt or even be uncomfortable for you.
9. It is possible that this study may help you and other people speak more clearly.
10. If you agree to participate in this study you will not receive a gift or money.
11. If you agree to participate in this study, you can stop at any time.   

  You are deciding whether or not to be in this study.  Signing this form (or saying “yes”) means that you have decided to participate and that all your questions about the study have been answered. You and your parents will be given a copy of this form to keep. 

______________________________                              __________________
Printed Name of Subject                                                     Date 

______________________________                              __________________
Signature of Subject                                                           Date 

______________________________                              __________________
Printed Name of Witness                                                     Date 

_____________________________                               __________________
Signature of Witness                                                           Date 

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Signature of Investigator                                                      Date    

Identification of Investigators     

Principal Investigator     

Julie K. Robinson, Ph.D.  University of Nebraska at Kearney   

Office: 865-8888                     

Secondary Investigator     

Samuel Johnson, Ph.D.  University of Nebraska at Kearney      

Office: 865-9999  

Approved 06/28/17