Form 1793 UAB CIREN Assent form child

ASSENT FORM
TITLE OF RESEARCH:

Crash Injury Research and Engineering Network (CIREN)

IRB PROTOCOL:

IRB-100606010

INVESTIGATOR:

Shannon Carroll, MD

SPONSOR:

National Highway Traffic Safety Administration, U.S. Dept. of
Transportation

The investigators named above are doing a research study.
These are some things we want you to know about research studies:
We are asking you to be in a research study. Research is a way to test new ideas. Research helps
us learn new things.
Whether or not to be in this research is your choice. You can say Yes or No. Whatever you
decide is OK. We will still take good care of you.
Why am I being asked to be in this research study?
You are being asked to be in the study because you have been in a car crash.
What is the study about?
The doctors need to learn more about the best way to protect kids in cars.
What will happen during this study?
If you agree to be in this study, you will




Have a nurse ask you questions about the car crash.
Have a survey with questions about how you feel sent to your house in 6 months and one
year.
The doctors will look at your x-rays.

Will the study hurt?
This study will not hurt at all. It just involves answering questions about how you were sitting in
the car.
What else should I know about the study?
We will ask your parents about the vehicle you were riding in at the time of crash. A crash
investigator will look at the vehicle.
What are the good things that might happen?

Page 1 of 2

Version Date: 01/05/2021

UAB IRB
Approved
21-Oct-2022
until
20-Oct-2023

The doctors will discuss the damage to your vehicle and your injuries over with a group of
engineers. They will decide how each of your injuries happened. This information will help
researchers make vehicles safer.
What if I don’t want to be in this study?
You do not have to be in the study if you do not want to. The doctors will still take care of your
injuries. If you don’t want to be in this study, you can continue to get your medical care at
Children’s Hospital.
Who should I ask if I have any questions?
If you have any questions about this study, you or your parents can call Dr. Carroll at (205) 9755247.
Do I have to be in the study?
No, you do not have to be in the study. Even if you say yes now, you can change your mind later.
It is up to you. No one will be mad at you if you don’t want to do this.
Signatures
Before deciding if you want to be in the study, ask any questions you have. You can also ask
questions during the time you are in the study.
If you sign your name below, it means that you agree to take part in this research study.
Your Name (Printed)

Age

Your Signature

Date

Signature of Person Obtaining Consent

Date

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Version Date: 01/05/2021