Attachment F

ATTACHMENT F

Sample Statement of Assent

Important note: The eight different survey sites may modify the Child Assent Form to meet the requirements of their local Institutional Review Boards (IRBs). ACF will provide this document as a model of the most basic content that should be included in the form the sites submit to their IRBs.

SAMPLE STATEMENT OF ASSENT

EVALUATION OF ADOLESCENT PREGNANCY PREVENTION APPROACHES (PPA)

(Sponsored by the United States Department of Health and Human Services)

An adult at ____________has explained to me the Evaluation of Adolescent Pregnancy Prevention Approaches (PPA). I was told that I have been selected to be a part of the study and that my parents/guardians have agreed to my participation. The study was described to me and any questions I had were answered. I understand that the information I provide is private and will not be provided to people outside of the study or shown to my parents or teachers. I also understand that I do not have to answer any questions that make me feel uncomfortable. I understand that participation is voluntary, and I agree to participate in the study.

______________________ _________________________ _______________

Name Signature Date

Email: _________________________________________

Cell phone: ( ) _________ - ______________

Area code

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I certify that the staff members assigned to explain the study to participants were trained to do so in terms participants would understand.

_________________________________________

Melissa Thomas

Survey Director

Signature Date

2