Core Data Set Youth Assent elemen school_12-09-11

National Child Traumatic Stress Initiative (NCTSI) Evaluation Sample Informed Consent—Youth Assent Version (Suggested Content and Wording)

I, ___________________, have talked with my parents about helping (NCTSN center program name). I know that they will ask me how I feel and will ask questions about me and my family. I know that I can stop helping at any time. No one will be mad at me. (NCTSN center program name) will not tell anyone my name or my answers. If someone is hurting me, (NCTSN center program name) will tell the police. Nobody will give me gifts for helping.

Yes, I will help (NCTSN center program name).

Name of the Child (Type or Print Full Name): ______________________________________

Signature of Child:

________________________________________ Date: ___/___/____

I, ___________________________, have read the preceding and agree to the participation of my child.

(Caregiver/Guardian) Name:_____________________________ Date: ___/___/____

Caregiver’s Signature: ____________________________ Date: ___/___/____

Project Name Team’s Certification

I certify that I have explained to the above individual the nature and purpose of the project as well as the potential benefits and risks associated with participating in the project. I also have answered any questions that have been raised and witnessed the above signature.

Signature of Witness: _____________________________ Date: ___/___/____

February 2010 NCTSI Evaluation-Youth Assent Page 1