ࡱ> JLI Gbjbj11 DBSSe8 8 8tR$'vv(X'Z'Z'Z'Z'Z'Z'$)5,\~'~'4'@@@X'@X'@@:#,$M"e2]Jj($ D''0'2$R,,$$,$"@  ~'~'~',8 X: Assent Script v. 2/01/2016 [Children ages 8-12] The information highlighted in yellow is guidance. DELETE THIS AND ALL OTHER HIGHLIGHTED INSTRUCTIONS BEFORE SUBMITTING. RSRB Requirements: Use of Subject: The assent script must use the term research subject rather than participant or volunteer. Use of 2nd Person: The assent script must be written in the 2nd person, just as you will be talking with the child who is a potential subject (e.g., You are being asked to take part in a research study about). Pagination: Maintain page numbering already inserted in the footer (e.g., 2 of 4). Version Date: Manually type the date in the footer, rather than selecting Insert Date from the toolbar to avoid automatic logo each time the document is opened. Margins: Maintain the bottom margin of at least 2 inches to provide space for watermarking upon approval. Assent Script [Insert Title of Study] Principal Investigator: [Insert] We are doing a research study. These are some things we want you to know about research studies: Your parent needs to give permission for you to be in this study. You do not have to be in this study if you dont want to, even if your parent has already given permission. If you start, you may stop being in the study at any time. If you decide to stop, no one will be angry or upset with you. [If a treatment protocol, add: Your doctors will still continue to take good care of you.] [Delete last two paragraphs if not applicable, e.g., pediatric cancer treatment.] Why are you being asked to be in this research study? Provide a simple explanation of why the child is invited to participate (if appropriate) and briefly describe the general purpose of the study. What will happen during this study? Provide a simple explanation of procedures. Avoid describing study procedures in lengthy detail (lists often work well). Indicate the length of time of the individual subjects active involvement and any applicable risks/discomforts. Who will be told the things we learn about you in this study? Describe who will have access to the information collected. Be clear about whether pregnancy, illegal activity, psychological tendencies will be reported and to whom. Be clear about what parents and teachers will be told (e.g. The information we collect about you will be kept private. Only the people working on this study will be able to look at the information we collect. It will not affect how your doctor [or teacher, etc.] treats you.). What if you or your parents dont want you to be in this study? (If applicable) For biomedical research, use this section to briefly discuss appropriate procedures or courses of treatment, if any, that might be advantageous to the subject (e.g., standard treatment, no treatment, comfort care or participation in another study). For other types of research, use this section to discuss appropriate procedures or options, if any, that might be advantageous to the subject (e.g., not participating or alternative options). If the study is minimal risk and the only alternative is to not to participate this section is not necessary and should be deleted. Will you get any money or gifts for being in this study? Choose ONE applicable sentence. You will not receive any money or gifts for being in this study. -OR- You will be given XX for being in this study. If subjects are to be paid for participation, specify the amount, schedule of payment and conditions for payment. When applicable, payments should be based on a prorated system. If subjects will be given some token gift (e.g., a toy), instead of payment, describe in appropriate terms. Remember, being in this study is up to you and your parents. If you dont feel like you want to do this right now, just tell us. Even if your parent says it is all right for you to be in this study, you dont have to. If you start, you may stop being in the study at any time. If you decide to stop, no one will be angry or upset with you. It is important that you understand what you will do in this study. Please ask us any questions you have at any time. What questions do you have? It is the responsibility of the person obtaining assent to ensure that the child understands the study to an age-appropriate degree. Asking questions can help children decide. Do you want to be in the study? Subject Name: ___________________________________________________ (PRINTED BY Person Obtaining Assent) Person Obtaining Assent I have read this form to the subject and/or the subject has read this form. An explanation of the research was given and questions from the subject were solicited and answered to the subjects satisfaction. In my judgment, the child has demonstrated comprehension of the information. I have given the child adequate time to consider the study before providing assent. My signature below documents the subjects assent to participate in this research study. Name and Title (Print) Signature of Person Obtaining Assent Date     RSRB Case Number: 000XXXX Page  PAGE 3 of  NUMPAGES 3 Version Date: xx/xx/20xx 0@TUYa~辦v^vvE1 *hwdhp56;B*OJQJ^JaJph. *hwdha56B*OJQJ^JaJph. *hwdh]$h56B*OJQJ^JaJph. *hwdhjp"56B*OJQJ^JaJph. *h d]h d]56B*OJQJ^JaJph( *hwd56B*OJQJ^JaJph( *huZT56B*OJQJ^JaJph. *hwdhwd56B*OJQJ^JaJph01  ]  m n | }  b c 1$gd $1$a$gd & Fgd & Fgdwdgdwdgd$a$gd d]$a$gd1 9 ; D H I N O V i n ѹs[Cs+s[. *hwdhp56B*OJQJ^JaJph. *hwdhGL56B*OJQJ^JaJph. *hwdh 56B*OJQJ^JaJph. *hwdhjp"56B*OJQJ^JaJph1 *hwdhwd56B*H*OJQJ^JaJph( *hwd56B*OJQJ^JaJph. *h;hwd56B*OJQJ^JaJph( *hjp"56B*OJQJ^JaJph1 *hwdhjp"56;B*OJQJ^JaJphn p q w     R S Y Z ] y     ζqζζqqqYqA. *hwdhwd56B*OJQJ^JaJph. *hwdhXzi56B*OJQJ^JaJph( *hwd56B*OJQJ^JaJph. *hwdhH 56B*OJQJ^JaJph. *hwdhp56B*OJQJ^JaJph. *hwdhjp"56B*OJQJ^JaJph. *hwdh 56B*OJQJ^JaJph1 *hwdh 56B*H*OJQJ^JaJph 3 ; m n | } iTD/( *hahaB*OJQJ^JaJphhaB*OJQJ^JaJph(hvghjp"5B*OJQJ^JaJph+ *hahjp"5B*OJQJ^JaJph+ *haha5B*OJQJ^JaJph(hvgh 5B*OJQJ^JaJph+hvghjp"5;B*OJQJ^JaJph%hvghjp"B*OJQJ^JaJph( *hwd56B*OJQJ^JaJph. *hwdhXzi56B*OJQJ^JaJph   a c L ıu`M:M'M%hKjh B*OJQJ^JaJph%hKjhqI1B*OJQJ^JaJph%hKjhgB*OJQJ^JaJph(hKjhg5B*OJQJ^JaJph+hKjhg5>*B*OJQJ^JaJph%hvghB*OJQJ^JaJph%hvghgB*OJQJ^JaJph%hvghIB*OJQJ^JaJph"hjp"5B*OJQJ^JaJph%hvghjp"B*OJQJ^JaJph+hvghahaB*OJQJ^JaJphL k l 4?QT{ðoZZZG%hKjhW9B*OJQJ^JaJph( *hKjhQOB*OJQJ^JaJph+hKjhg5>*B*OJQJ^JaJph+hKjhgB*OJQJ^JaJphwh( *hKjhqI1B*OJQJ^JaJph%hKjhqI1B*OJQJ^JaJph%hKjhgB*OJQJ^JaJph( *hKjhIB*OJQJ^JaJph( *hKjhgB*OJQJ^JaJph 4(gh Z  (#$gd `0gd &`0p@ P !$`'0*gdgdJ_`Qs]]G+ *hvgh6B*OJQJ^JaJph+hvghWjG5>*B*OJQJ^JaJph%h5>*B*OJQJ^JaJph+hvghQO5>*B*OJQJ^JaJph *hvghu OJQJ^JaJ( *hvghgB*OJQJ^JaJph( *hvghQOB*OJQJ^JaJph%hvghgB*OJQJ^JaJph+hvghg5>*B*OJQJ^JaJphQabӽjWA++hvghQO5>*B*OJQJ^JaJph+hvghg5>*B*OJQJ^JaJph%hvghgB*OJQJ^JaJph(hvghWjG6B*OJQJ^JaJph(hvgh+\t6B*OJQJ^JaJph% *hy'#6B*OJQJ^JaJph+ *hvghQO6B*OJQJ^JaJph+ *hvgh+\t6B*OJQJ^JaJph+ *hvgh6B*OJQJ^JaJph+ *hvghWjG6B*OJQJ^JaJph '(BJ]d fghҼzzhU<)%hvghgB*OJQJ^JaJph0hvghQOB*OJQJ^JaJmHnHphu% *hvghQO56OJQJ^JaJ" *hvghQO6OJQJ^JaJ *hs|fOJQJ^JaJ *hvghQOOJQJ^JaJ *hs|fhQOOJQJ^JaJ( *hs|fhs|fB*OJQJ^JaJph+hvghg5>*B*OJQJ^JaJph+ *hjhQO>*B*OJQJ^JaJph.hvghQO56>*B*OJQJ^JaJph Ӿ{hR=h-hKjB*OJQJ^JaJph(hvghg6B*OJQJ^JaJph+ *hvghQO6B*OJQJ^JaJph%hvghgB*OJQJ^JaJph( *hvghWjGB*OJQJ^JaJph+ *hvghg5B*OJQJ^JaJph. *hvghg5>*B*OJQJ^JaJph( *hvghgB*OJQJ^JaJph+hvghg5>*B*OJQJ^JaJph+h#hg5>*B*OJQJ^JaJph 8CXYZ/IKĴwfTB0# *h^hy'#@OJQJ^JaJ#hvgh95@OJQJ^JaJ#hvghw5@OJQJ^JaJ hvghw@OJQJ^JaJ *hy'#OJQJ]^J *hPhy'#OJQJ]^J *h8"Ohy'#OJQJ]^J *h8"Ohs|fOJQJ]^J *hrOhs|fOJQJ]^J%hvghgB*OJQJ^JaJph( *hvghsnB*OJQJ^JaJph%hvghKjB*OJQJ^JaJphZ[8:/K` 1$7$8$H$gd$a$gd $ 0*$a$gdU 0*$gd $ 0*$a$gdy'# $ 0*$a$gd 0*$gd 0*$gd*+,@_`z˹xgSB1B hvgh^;@OJQJ^JaJ hvgh9@OJQJ^JaJ&hvgh95>*@OJQJ^JaJ h!j5>*@OJQJ^JaJ hvg5>*@OJQJ^JaJ h^hU@OJQJ^JaJh@OJQJ^JaJ hhvg@OJQJ^JaJ#hhvg5@OJQJ^JaJ#hvgh"5@OJQJ^JaJ#hvgh95@OJQJ^JaJ h^hy'#@OJQJ^JaJFNq{+޿޿ޜ}q}aO?O?hvgh1OJQJ\^JaJ"hvgh1>*OJQJ\^JaJhvgh15OJQJ^JaJh\gOJQJ^JaJhvgh1OJQJ^JaJhvgh1>*OJQJ^JaJ#hvgh95@OJQJ^JaJ hvghU@OJQJ^JaJhU@OJQJ^JaJ hvghw@OJQJ^JaJ hvgh9@OJQJ^JaJ hvgh^;@OJQJ^JaJBDEFGgdOrgdggd9 1$7$8$H$gd  %&'(7=?ABDEFG䵤䵤䛗hvgh1OJQJ\^JaJh8"Oh8"OOJQJh!h1VCJOJQJ^JmHnHu%jhvgh8"OCJOJQJU^J *hvgh8"OCJOJQJ^Jh8"OCJOJQJ^Jhvgh8"OCJOJQJ^Jh|Ujh|UU#B00P&P:p1V/ =!"#$@ % Dp^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH D`D gNormalCJOJQJ_HmH sH tH @ g Heading 1I$$ 8`0p@ P !$`'0*@&a$ 5OJQJ|@| g Heading 3C$ 8`0p@ P !$`'0*@& 6OJQJDA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List .O. gtoa  (#$4 @4 gFooter  !>B@> g Body Text1$ 6OJQJ4"4 gHeader  !RR2R WjGBody Text Indent 2hdx^hH@BH { Balloon TextCJOJQJ^JaJ6U`Q6 l Hyperlink >*B*phB'`aB IComment ReferenceCJaJ8@r8 I Comment TextCJ@j@qr@ IComment Subject5\FV`F `7FollowedHyperlink >*B* phPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] GB dddgn  L QG  ZG+249DFg!@ @H 0(  0(  B S  ?`t`t  H  H9*urn:schemas-microsoft-com:office:smarttagsState9*urn:schemas-microsoft-com:office:smarttagsplace Ϡnn// (EH /JEH330@@YYDKK]ylmmnn||}}( (         //+,--..`zEH0@@YYDKK]ylmmnn||}}      //EH4h]D_pHJL_hhh^h`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHhpp^p`OJQJo(hHh@ @ ^@ `OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH4h]D_p                 cOr+mp>"n{I^I u O:H B ;a6cjp"y'#A$`T%& )?I)b-a/n30qI13gV4L 77W9^;D{4EOFWjGQ;I :J]J<L)aLO O8"O1>RuZT|UUwX\8YaR[ d]+bd}*deifs|fRg\gvg]$hXzi!jKjlyl9p@qt+\tpbt)1w\_=<ap{OF|K I<&L+B< uGLxpsXm@ve0]1a?{{>"?c(% ]sn!K2D '31VI,rOEQOwd`7Pw"Bm#&!o MH l rVY]]Ijg[,79z@////G@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial?= *Cx Courier New5. .[`)Tahoma;WingdingsA$BCambria Math"1h B' B'8F $ $!243q HX ?g2!xx General AssentOHREekflagg  Oh+'0t  $ 0 < HT\dlGeneral AssentOHRENormalekflagg4Microsoft Office Word@F#@@z1]@A2]՜.+,0  px  version 2-Oct-2007UNC-CH$  General Assent Title  !#$%&'()*+,-./012345678:;<=>?@BCDEFGHKRoot Entry F4.e2]M1Table",WordDocumentDBSummaryInformation(9DocumentSummaryInformation8ACompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q