AttI_Drexel_Assent Form

Version Date: 3.22.19
Drexel University
ASSENT FORM FOR CHILDREN/MINORS IN A RESEACH STUDY
You are being asked to participate in a research study. We would like to ask you a
couple of questions about what it was like to have us in your home, and your feelings
about emergencies. We would like to use a digital recorder to record what you say so we
can write it down later, and share your thoughts with other people who are helping us
with this project.
If we find out someone has hurt you, we must report this to a responsible adult, but not
the person who has hurt you.
Child’s Assent: I have been told about the study and know why it is being done and what
to do. I also know that I do not have to do it if I do not want to. If I have questions, I can
ask Reggie or Iris from the Drexel study team. I can stop at any time.
My parents/guardians know that I am being asked to be in this study.
____________________________________
Child’s Signature

______________
Date

List of Individuals Authorized to Obtain Assent
Name

Title

Phone #

Reginald Combs-Harris
Iris Cruz
Katie Feehan
Renee Turchi

Social Worker
Community Health Worker
Program Coordinator
Principal Investigator

215-427-4376
215-427-8597
215-427-8353
215-427-5331

APPROVED Human Research Protection Protocol # 1903007082
Approval Date: 07/02/2019

Office of Human Research
Revised: 02-03-2013

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Initials: __________

Approved on 02-JUL-2019 - Drexel IRB Protocol #: 1903007082 - Expires on: 01-JUL-2020