Student LIC Assent Form

Student Assent Form

LIC

ASSENT FORM

Dear Student,

You are being asked to participate in a survey that asks questions about you, your friends, and your school. It will take about 35-45 minutes to answer the questions.

This is not a test. There are no right or wrong answers and you will not be timed. The answers you give are very important. Please read each question carefully and answer it based on what you really know or do. Answer the questions truthfully and as best as you can.

The survey is anonymous and confidential. Do not put your names anywhere on the survey or the answer sheet. No one will ever be able to connect you with your answers. Your answers are private.

The survey is voluntary. You do not have to complete this survey, but we hope that you will.

Thank you.

Yes, I am willing to take the survey.

_________________________________________ ______________________

Print Your Name Date

Birth date: ___________________________________/________________/______________

Month Day Year

Please remove this page carefully from the survey

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Permission to use specific items may be required