Signature Block for Children [Delete if not applicable] Your signature documents your permission for the named child to take part in this research. Printed name of child Signature of parent or individual legally authorized to consent to Date the general medical care Parent Individual legally authorized Printed name of parent or individual legally authorized to consent to consent to the child’s to the child’s general medical care general medical care (See note below) Note: Investigators are to ensure that individuals who are not parents can demonstrate legal authority to consent to the child’s general medical care. Contact legal counsel if any questions arise. Signature of parent Date Printed name of parent If signature of second parent not obtained, indicate why: (select one) The IRB determined that the permission of one Second parent is incompetent parent is sufficient. Second parent is not reasonably available [Delete if the IRB did not Only one parent has legal responsibility for make this determination] Second parent is deceased the care and custody of the child Second parent is unknown [Add the following block if you will document assent of children] Obtained Not obtained because the capability of the is so limited that the child cannot reasonably be consulted. Waived by the IRB because the intervention or procedure involved in the research out a prospect of direct benefit that is important to the health or well-being of the child and is available only in the context of the research. Assent [Add the following block to all consents] Signature of person obtaining consent and assent Date Printed name of person obtaining consent [Add the following block if a witness will observe the consent process. E.g., short form of consent documentation or illiterate subjects.]
[Delete if not applicable] Signature Block for Children Your signature documents your permission for the named child to take part in this research. Printed name of child Signature of parent or individual legally authorized to consent to the general medical care Date Parent Individual legally authorized to consent to the child’s general medical care (See note below) Printed name of parent or individual legally authorized to consent to the child’s general medical care Note: Investigators are to ensure that individuals who are not parents can demonstrate legal authority to consent to the child’s general medical care. Contact legal counsel if any questions arise. Signature of parent Date Printed name of parent If signature of second parent not obtained, indicate why: (select one) The IRB determined that the permission of one parent is sufficient. [Delete if the IRB did not make this determination] Second parent is deceased Second parent is unknown Second parent is incompetent Second parent is not reasonably available Only one parent has legal responsibility for the care and custody of the child [Add the following block if you will document assent of children] Assent Obtained Not obtained because the capability of the is so limited that the child cannot reasonably be consulted. Waived by the IRB because the intervention or procedure involved in the research out a prospect of direct benefit that is important to the health or well-being of the child and is available only in the context of the research. [Add the following block to all consents] Signature of person obtaining consent and assent Date Printed name of person obtaining consent [Add the following block if a witness will observe the consent process. E.g., short form of consent documentation or illiterate subjects.]