Form 1773 Emory CIREN Assent form for minor subjects

STUDY00005031
IRB Approved
9/27/2022

EMORY UNIVERSITY/CHILDREN’S HEALTHCARE OF ATLANTA ASSENT FORM FOR
MINOR SUBJECTS Study
Title: Crash Injury Research and Engineering Network (CIREN), Emory/Grady Center Principal
Investigator: Jonathan Rupp, Ph.D., Department of Emergency Medicine
______________________________________________________________________________
This page to be filled out by research team at time assent is obtained:
Subject’s Age: _____years (If the child is younger than 6 years old, assent is not required.)
Subject’s Name: ______________________________
Check one box:
______________________________________________________________________________
 This child is 6 to 10 years old — must obtain subject’s verbal assent (subject’s signature not required)

_____________________________________________________________________
Signature of person soliciting assent of 6 to 10-year-old subject Date Time

______________________________________________________________________________

 This child is 11 to 17 years old — must obtain subject’s signature on page 2 of assent form to
document assent
______________________________________________________________________________



In my opinion, this child is unable to provide informed assent for non-age-related reasons, and
the PI for this study has been informed of this determination.
 Reason(s):_________________________________________________________
__________________________________________________________________
__________________________________________________________________

_____________________________________________________________________
Signature of person soliciting assent (if above box is checked) Date Time
______________________________________________________________________________

STUDY00005031
IRB Approved
9/27/2022

EMORY UNIVERSITY/CHILDREN’S HEALTHCARE OF ATLANTA ASSENT
FORM FOR MINOR SUBJECTS
Study Title: Crash Injury Research and Engineering Network (CIREN), Emory/Grady Center
Principal Investigator: Jonathan Rupp, Ph.D., Department of Emergency Medicine
INFORMATION ABOUT THIS STUDY:
Why are you being asked to be in this study? You are being asked to be in a study because you were
involved in a motor-vehicle crash.
Why is this study taking place? We are working with the United States Department of Transportation to
study how and why people get injured in car crashes.
What will happen to you if you take part in the study? We will ask you questions about the crash that
you were in. We will also take pictures of the bumps and bruises on your body that were caused by the
crash and some measurements of how long your legs are.
Will any part of the study cause pain or make you feel uncomfortable? No part of this study should
cause you pain. You may feel uncomfortable talking about you’re your crash.
Who can you ask if you have questions about this form? You can ask the investigator who has given
you this form any questions you may have.
Can you change your mind about being in the study at any time? You can change your mind about
participating in this study if you decide you don’t want to at a later time. You do not have to be in this
study if you don’t want to.

For subjects 11 to 17 years old: if you agree to be in this study, please sign your name below.

________________________________________________________________________
Signature of 11 to 17-year-old Subject Date Time

________________________________________________________________________
Signature of person soliciting assent of 11-17 year old Subject Date Time