ࡱ> ?A>a bjbj[[ 4*9bE\9bE\GD D 8,rHH(ppp_u giiiiii$ZV__ppjppggpRS0fEfflfD > : University of North Carolina at Chapel Hill Assent to Participate in a Research Study Minor Subjects (7-14 yrs) ________________________________________________________________________ Consent Form Version Date: 2/21/2016 IRB Study # 07-0352 Title of Study: Successful Transition to Adulthood with Therapeutics (STARx) Person in charge of study: Maria Ferris Where they work at -Chapel Hill: Unc Kidney Center Other people working on this study: Kristi Bickford, Sarah Cohen, Karina Javalkar, Alex Phillips, Mia Lassiter, Ali Annaim, Meredith Johnson, Meaghan Nazareth The people named above are doing a research study. These are some things we want you to know about research studies: Your parent needs to give permission for you to be in this study. You do not have to be in this study if you dont want to, even if your parent has already given permission. You may stop being in the study at any time. If you decide to stop, no one will be angry or upset with you. Sometimes good things happen to people who take part in studies, and sometimes things happen that they may not like. We will tell you more about these things below. Why are they doing this research study? The reason for doing this research is to learn more about how young people who have health conditions grow up to become healthy adults. We want to find out what young people do and do not know about their health. We also want to find out how having a health condition has affected other parts of your life like your friends, family, and overall happiness. This will help doctors know how to better teach other kids about their health and taking care of themselves. Why are you being asked to be in this research study? You are being asked to be in this study because you are a young person who has a health condition and will grow up to be an adult with a health condition one day. How many people will take part in this study? If you decide to be in this study, you will be one of many people in this research study. Right now, we have about 850 people in our study and are hoping to add about 100 more people in the study this year. What will happen during this study? During this study, you may be asked to answer questionsasked by a researcher and/orfill out surveys on your own. These questions and surveys willhelp us learn how much you know and don't know about your health, medicines, and taking care of yourself. They will also tell us other information that is important in learning how to best help you. You may be asked to complete one or moresurveysduring your doctor appointments, but you have the option of choosing not to answer any questions that you do not want to.We may askif it is ok to record your answers to some questions with a digital recorder. Youcan choose whether or notit is ok to be recorded by checkingone of the lines below that best matches your choice: _____ OK to record me during the study _____ Not OK to record me during the study This study will take place atthe Children'sHospital or the Ambulatory Care Clinic (ACC)and will last until you or your parent withdraws consent. Who will be told the things we learn about you in this study? The only people who will be told the things we learn about you in this study are your parents, your doctor, and the people listed on the first page of this form. What are the good things that might happen? People may have good things happen to them because they are in research studies. These are called benefits. There is little chance you will benefit from being in this research study. What are the bad things that might happen? Sometimes things happen to people in research studies that may make them feel bad. These are called risks. We do not think any bad things will happen to you if you take part in this study. Youshould report any problems to the researcher Will you get any money or gifts for being in this research study? You may get a gift card for up to $15.00 if you complete certain scales. Who should you ask if you have any questions? If you have questions you should ask the people listed on the first page of this form. If you have other questions, complaints or concerns about your rights while you are in this research study you may contact the Institutional Review Board at 919-966-3113 or by email to IRB_subjects@unc.edu. If you sign your name below, it means that you agree to take part in this research study.  ______________________________________________________ Sign your name here if you want to be in the study ____________________ Date ______________________________________________________ Print your name here if you want to be in the study  ______________________________________________________ Signature of Research Team Member Obtaining Assent ____________________ Date ______________________________________________________ Printed Name of Research Team Member Obtaining Assent     07-0352 Assent Form Ages 7-14 Page  PAGE \* Arabic \* MERGEFORMAT 1 of  NUMPAGES \* Arabic \* MERGEFORMAT 3 +,UVo @ Z h  < q t nGtDEh1n<"VWQRSFGHI￲h ch 'PJh ch 'CJPJaJh ch 'CJPJaJhhR,Vh7&c h '0J>*hhb^h chvh ' h '5\ h '0JB= q t GEQRSGkd$$Ifed-lx;B t634Bait-lx$Ifed-lxGIJKLIDed-lxWkd$$Ifed-lx0; BB t634Bait-lx$IfWkdp$$Ifed-lx0; BB t634Bait-lxIJKLMABCDEFGHJKMNPQSTUVWXY`avw|}ÿÿÿûûññÿÿÿjh '5U*hc5mHnHu* h@5jh '5Uh ch#^h@h3jh3Uhh ch 'PJh ch 'CJPJaJ h 'PJh ch 'CJPJaJ6LMBDZWkd$$Ifed-lx0; BB t634Bait-lx$IfGkdR$$Ifed-lx;B t634Bait-lxDEFGIJLMOPRSTUVWX dgd@ed-lxWkd3$$Ifed-lx0; BB t634Bait-lxXY  $HAgd c 21h:p '/ =!"#$% n$$Ifed-lx!vh#vh:V  t6,534Bit-lxo$$Ifed-lx!vh#vh#v:V  t6,534Bit-lxo$$Ifed-lx!vh#vh#v:V  t6,534Bit-lxn$$Ifed-lx!vh#vh:V  t6,534Bit-lxo$$Ifed-lx!vh#vh#v:V  t6,534Bit-lxo$$Ifed-lx!vh#vh#v:V  t6,534Bit-lx s666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ OJPJQJ_HmH nH sH tH J`J  'Normal dCJ_HaJmH sH tH DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List >@> @0HeaderdH$.. @0 Header Char> @> @0FooterdH$.!. @0 Footer CharR2R @0 Balloon Text dCJOJQJ^JaJN/AN @0Balloon Text CharCJOJQJ^JaJ`^@R` '0 Normal (Web)ddd[$\$CJOJPJQJ^JaJ*W`a*  '`Strong5\PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. J;̊iN $AI)t2 Lmx:(}\-i*xQCJuWl'QyI@ھ m2DBAR4 w¢naQ`ԲɁ W=0#xBdT/.3-F>bYL%׭˓KK 6HhfPQ=h)GBms]_Ԡ'CZѨys v@c])h7Jهic?FS.NP$ e&\Ӏ+I "'%QÕ@c![paAV.9Hd<ӮHVX*%A{Yr Aբ pxSL9":3U5U NC(p%u@;[d`4)]t#9M4W=P5*f̰lk<_X-C wT%Ժ}B% Y,] A̠&oʰŨ; \lc`|,bUvPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!R%theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] "* ILDX5WY^!L# @0(  B S  ?_GoBack``GIJLMOPRS|GIJLMOPRS3<DWFG`avw|-lx '3jD4ER,V#^b^ c7&clc3cBv"g@XeGI@@UnknownG*Ax Times New Roman5Symbol?. *Cx ArialArial7.@Calibri5. .[`)TahomaA$BCambria Math"1hXEXEg "g "!0>>:HX  $P@2!xx Slattery, John AJordanOh+'0`   ( 4@HPXSlattery, John ANormalJordan2Microsoft Office Word@@ޚ@ޚg՜.+,0 hp  0The University of North Carolina at Chapel Hill" >  Title  !"#$%&'()*+,-/012345789:;<=@Root Entry FBData 1TablefWordDocument4*SummaryInformation(.DocumentSummaryInformation86CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q