Assent Form - Drexel University Children/Minors

Attachment G. Assent Form

DREXEL UNIVERSITY

Assent form for children/minors to take part in a research study conducted at

Drexel University’s Center for Public Health Readiness and Communication

You are being asked to participate in a research study. You are being asked to participate because you have special health care needs. Participation in this research study is completely voluntary.

Whether or not you take part in the research study is up to you. You can choose not to take part in it, you can agree to take part now and change your mind later, and if you decide to not be a part of this research no one will hold it against you. Feel free to ask all the questions you want before you decide. This study is designed to understand the communications needs of children with special health care needs during disasters.

If you volunteer to participate in this study, you will be asked to complete a short questionnaire providing information about yourself. Then, we will guide you through a set of questions about your disaster information needs. After you answer the questions, you are done with the study.

You may choose to not answer any questions that are asked of you and it will not be held against you. Efforts will be made to limit access to any personal information you provide. Your answers will not be shared with anyone. You will also be given a $25 gift card for completing this study.

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:

Dr. Renee Turchi

Dornsife School of Public Health

Drexel University

3215 Market Street

Philadelphia, Pa 19104

Phone: 267-359-6051

Email: Renee.Turchi@DrexelMed.edu

Dr. Esther Chernak, MD, MPH

Dornsife School of Public Health

Drexel University

3215 Market Street

Philadelphia, PA 19104

Phone: 267-359-6038

Email: dec48@drexel.edu

Jennifer Plumb
Drexel A.J. Autism Institute
3020 Market St
Philadelphia, PA 19104
Phone: 215-571-3438
Email: jcp94@drexel.edu

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 Day Phone # 24 Hr. Phone #