Assessment of Executive Function for the National Children's Study

Attach. 26 Child Assent Form OMB #: 0925-0661

Executive Function Expiration Date: 06/30/2015

Child Assent Form

Assessment of Executive Function for the National Children’s Study

IRB#1101S94592

After a brief warm-up, the examiner says to the child…

I have some games for you to play today. In some of the games I will ask you some questions about words and pictures. There are puzzles and games on a computer too. Your [parent] said it is OK for you to play if you want to. You don’t have to play if you don’t want to. No one will be upset with you if you decide you do not want to play the games. You can stop anytime you want to. Your [parent] will be [describe where parent will be; e.g., over there, right out here]. You can tell me whenever you want to stop, or if you need to go to the bathroom or get a drink of water. Does that sound OK? Do you have any questions for me?

For very young children (some will be as young as 30 months), we will simplify and adapt the description to the child’s level of comprehension.

Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0661). Do not return the completed form to this address.