Assent for Children Age 5-14 - English

Attachment F: Zika Investigation Assent for Children aged 5–14 Years (Flesch-Kincaid reading level – English: 5.6)

We are trying to learn how many people in this area have been infected with a new virus called ‘Zika.’ Zika virus can cause your skin to get red and itchy or your body to feel hot. We want understand more about things people can do to stop them from getting Zika virus. To do that, we would like to ask you or your parent some questions about things that you were doing over the past few weeks. We would also like to take a small sample of your blood, and of your spit and pee. This would mean that we would put a small needle in your arm and take some of your blood. It might pinch a little at first, but should not hurt too much. We will use the blood to see if you have ever had Zika virus. Your parent/guardian has said that it is OK for you to answer these questions and give the specimens I mentioned. Would that be OK with you?

Child’s Name:_______________________________________________________________

Name of permitting parent/guardian:______________________________ Date:___________