NOTE: Text that appears in BLUE is "help text" and will NOT be included in the printed ICD!

The consent form heading should reference the names of only those institutions that are participating in the protocol.  DELETE the institutions that are NOT involved in the research.
ALBERT EINSTEIN COLLEGE OF MEDICINE OF YESHIVA UNIVERSITY
MONTEFIORE MEDICAL CENTER
JACOBI MEDICAL CENTER
NORTH CENTRAL BRONX HOSPITAL 

BENJAMIN N. CARDOZO SCHOOL OF LAW
AZRIELI GRADUATE SCHOOL OF JEWISH EDUCATION AND ADMINISTRATION
BERNARD REVEL GRADUATE SCHOOL OF JEWISH STUDIES
FERKAUF GRADUATE SCHOOL OF PSYCHOLOGY
STERN COLLEGE FOR WOMEN
YESHIVA COLLEGE
SY SYMS SCHOOL OF BUSINESS
WURZWEILER SCHOOL OF SOCIAL WORK
DELETE “OF YESHIVA UNIVERISTY” if NOT a Yeshiva school.
OF YESHIVA UNIVERSITY

 Use this form for children ages 7-12, or older children who have the mental abilities of a 7-12 year old.  The language must be written at a 1st or 2nd grade level.
Child Assent Form

Title of Study: Include the exact title of the protocol.  Exceptions require CCI approval.  If you are NOT using the exact title, provide justification for the changes when submitting your CCI Research Application:

Principal Investigator (Researcher): Enter the PI's name here:
Phone Number of Investigator: Use a number that has frequent monitoring to ensure that messages will be returned in a timely manner.  Enter phone number (including area code) of PI here:

PURPOSE: (Why are you here?) In VERY simple terms, give the purpose of the study here.

Sample language.  MODIFY or REPLACE as required for your protocol:  We would like to talk to you about how you feel when other children say things about you.

PROCEDURES: (What will happen?) Explain in simple language what tests or procedures will be performed.

Sample language.  MODIFY or REPLACE as required for your protocol:  We would like to have you answer some questions about your feelings that may take about 15 minutes. You don’t have to answer any questions you don’t want to and you can stop at any time.

RISKS: (Will it hurt?) Inform the child if there may experience sadness, embarrassment, discomfort, uncomfortable feelings, etc.

Sample language.  MODIFY or REPLACE as required for your protocol:  No, the test is safe and does not hurt.  OR,  The questions may make you sad or embarrass you. 

BENEFITS: (How may it help you?) Explain if there is or is not any direct benefit to the child. If there is no direct benefit, this must be stated in the first sentence.

Sample language for no direct benefit to the child.  MODIFY or REPLACE as needed for your protocol:  The study will not help you feel better.  However, the information we learn may help other children in the future.

ALTERNATIVE PROCEDURES: (Can you say "No"?) Explain what the child’s alternatives may be.

Sample language.  Insert the name of the test, procedure (i.e. questionnaire) between the words “the” and “if”:  Yes.  You do not have to do the  if you do not want to. Sample language for most studies: You can stop at any time you want. Sample language for quetionnare studies: You do not have to answer any question that makes you feel uncomfortable or sad. Sample language.  Include in assent documents: No one will be upset with you if you say “no” or if you say “yes” and then change your mind.

You have been told about the study.
You have been told what you have to do.
You have been told that you do not have to do any of the tests if you do not want to.
You have also been told that you can stop any time you want, even after you begin.