Att. E2_Assent Form

Attachment E2 – Assent Form

Agreement to be in the Child Seat Belt Fit Study

1. I am asking you to take part in a research study because we are trying to learn about seat belts and how well they fit. We are doing this study for the Federal Government.

2. If you agree to be in the study, you will:

• Let us take your height and weight and other measures of your shoulders and legs.

• Test out the seat belts in a few cars and I will measure how well the seat belt fits you. You need to sit still while being measured. It is important that you know that I will have to touch you on your shoulders and hips when I measure you. Your parent/guardian will be with us at all times.

• Allow cameras in the car to record us. Only the people working on the study will be able to look at the pictures and videos.

• Help us today for about two hours.

3. There are no real risks to you being in this study. The cars will be turned off. In any reports that we write, we will not include your name or use any of the pictures or videos that we take.

4. Helping us today will give us the information we need to make sure that booster seats and seat belts are working safely.

5. Your parent has already given permission for you to be in this study. However, if you do not want to be in this study, you do not have to. Being in this study is up to you and no one will be upset if you do not want to or even if you change your mind later and want to stop.

6. You can ask any questions that you have about the study.

7. You will receive $50 for helping us. I will give the money to your parent/guardian when we are done.

8. Writing your name on this form means that you agree to be in the study.

_______________________________ _____________

(Your Name - Printed) (Age)

_______________________________ _____________

(Your Signature) (Date)

Statement of Person Who Obtained Assent

I have discussed the above points with the participant or, where appropriate, with the child participant’s legally authorized representative. It is my opinion that the participant understands the risks, benefits, and procedures involved with participation in this research study.

__________________________________________ _____________

(Signature of Person who Obtained Assent) (Date)