Attachment D3 OK Child Assent age 11-17 3-13-07

Child Assent 11-17 Version 3/13/07 IRB # 10345 Page Number 1

Attachment D3: Oklahoma Child Assent age 11-17

UNIVERSITY OF OKLAHOMA HEALTH SCIENCES CENTER

CHILDREN’S HOSPITAL OF OU MEDICAL CENTER

Child’s Assent to Voluntary Participation in a Research Project – Ages 11-17

Oklahoma PLAY (Project to Learn about ADHD in Youth)

Principal Investigator

Dr. Mark Wolraich

We are asking you to be in our research study. A research study is sort of like a science project at school.

Why is this study being done?

This study is being done to try and understand how attention, hyperactivity and impulsive problems and tic problems affect kids and their families. Being in the study does not mean that you have any of these problems. This study includes kids without these types of problems too.

What will I be asked to do?

If you decide to join the study once a year you will be asked to answer some questions on a questionnaire and talk to someone about your life. We will also ask your parent and teachers some questions about you. This will happen five times in the next five years.

All kids will be asked sensitive questions about tobacco and alcohol. Kids that are 11 and older will be asked sensitive questions about drug use & delinquent behavior. Kids that are 14 and older will be asked sensitive questions about sexual behavior.

Are there any bad things that can happen to me by being in the study?

You may be asked some questions that are embarrassing, if you do not want to answer a question you do not have to, but the ones you do answer you should answer truthfully. All answers that you give will be kept private. Unless we are required by law the things you tell us will not be given out to anyone. Under the law, we must report to the state suspected cases of child abuse or if you tell us you are planning to cause serious harm to yourself or others.

Are there any good things that can happen to me by being in the study?

This study will not make a difference in how your condition is treated, but it might make a difference in the future to someone else who may have the same type of problems you have.

Will I get something for taking time to do the study?

You will be given a gift certificate for answering questions.

Can I refuse to take part in the study?

Your parents have said that if you want to be in this study it is okay with them. You don’t have to be in the study if you don’t want to be. You can stop being in the study at any time and no one will be mad at you. You can ask any questions about this study at any time.

Signature: I would like to be in this study.

Printed Child’s Name:___________________________

Signature of Child:______________________________ Date:______________

S

Longitudinal Follow-up of ADHD Protocol Version 1.1 Page 46

ignature of Investigator:_________________________ Date:______________