Application for Ethical Review of Research Protocol

KORLE BU TEACHING HOSPITAL FOR MEDICAL
RESEARCH INSTITUTIONAL REVIEW
BOARD (KBTH-IRB) CHILD ASSENT FORM

SECTION A: PERSONAL DETAILS
        Title*:
        Surname*:
        First Name*:
        Middle Name:
        Place of birth*:
        Gender*:  
       

Date of Birth:(dd-mm-yyyy)

        Phone No*.
        Home Address:
        Email*:
        Postal Address:
        Nationality:   
        Occupation*:
        Emergency contact*:
        Name*:
        Department*:
        Institution*:
        Title*:
        Purpose:
        Length of participation:

SECTION B: GENERAL INFORMATION
Main Research:

SECTION C: POSSIBLE BENEFITS
        Benefits:
        Compensation:

SECTION D: POSSIBLE RISKS AND DISCOMFORTS
        Risk:

Voluntary Participation and Right to Leave the Research

You can stop participating at any time if you feel uncomfortable. No one will be angry with you if you do not wwant to participate.

Confidentiality

Your information will be kept confidential. No one will be able to know how you responded to the questions and your information will be anonymous.

SECTION E: CONTACTS FOR ADDITIONAL INFORMATION
  Contact information:

Your Rights as a Participant

This research has been reviewed and approved by the Institutional Review Board of Korle Bu Teaching Hospital for Medical Research (KBTH-IRB). If you have any questions about your rights as a research participate you can contact the IRB Officee beetween the hours of 8am-5pm through the landline 0302916438 or emaill address:rdo@kbth.gov.gh

SECTION F: VOLUNTARY AGREEMENT

By making a mark of thumb printing below, it means that you undestand and know the issues concerning this research study.If you do not want to participate in this study, please do not sign this assent form. You and your parents will be given a copy of this form after you have signed.

This assent form which describes the benefits, risks and procedures for the research titled has been reead and or explained to me. I habe been give an opportunity to have any questions about the research answered to my satisfaction.Iagree to participate.

        Child's Name:
        Researchers's name:
        Date: