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APPENDIX A: INFORMED CONSENT FORM

[INSTITUTIONAL LETTER HEAD and LOGO] centered at the top most

Informed Consent Form for [Identity of the particular group of individuals STUDY PARTICIPANTS (e.g.,
clients, patients, community leaders, service providers)

[Name of Proponents]

University of St. La Salle

[Research Title]

PART I: INFORMATION SHEET

INTRODUCTION

We are 4th year Psychology students from the University of St. La Salle who intend to gather data for our
undergraduate thesis. We are inviting you to be one of our research participants. If you have any
questions regarding this invitation, we would be glad to answer them.

PURPOSE OF THE RESEARCH

This study intends to “STATE THE STATEMENT OF THE PROBLEM” (single-spaced)

TYPE OF RESEARCH INTERVENTION

(If quantitative state the following:) Our study will require you to answer [State the number of items in
your instrument] items in a standardized instrument and will approximately take [State the estimated
duration in answering the instrument] to answer.

(If qualitative, state the following:) Our study will require you to answer a series of questions during the
interview which will approximately take 50 minutes to an hour.

PARTICIPANT SELECTION

Indicate why you have chosen this person to participate in this research. Indicate inclusion criteria.

VOLUNTARY PARTICIPATION

Your involvement in this research activity is entirely voluntary. If you prefer not to participate, you may
do so. If at any time you wish to terminate your participation or withdraw the information you have
provided us with, you may also do so.

PROCEDURES

A. You will be asked to answer a series of questions through a/n (survey or interview or both survey and
interview). Provide a brief description of the venue where the data-gathering will be conducted.

B. Explain the type of questions that the participants will be asked during the interview or the survey
(Use the description of your instrument as written in your approved research proposal).
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For Qualitative In-depth interviews:

COPY & PASTE HERE YOUR DATA GATHERING PROCEDURE. Inform the participant about the location of
the interview (or a preferred location of the participant) and identity of the interviewer. Assure the
participant that if he or she does not wish to answer any of the questions during the interview, the
interviewer will move on to the next question; that no one else but the interviewer will be present
unless the participant would like someone else to be there. Describe how the interview will be recorded
and kept confidential. Explain how long the study records will be kept and subsequently disposed.

For surveys:

COPY & PASTE HERE YOUR DATA GATHERING PROCEDURE. Describe how the survey instruments will be
distributed and collected. Inform the participant that he or she may answer the questionnaire
personally, or it can be read to him or her; answered aloud and written down by a member of the
research team. Assure the participant that if he or she does not wish to answer any of the questions, this
may be skipped and he or she can proceed to the next question. The information recorded is
confidential, name is not included in the forms, only a number will identify him or her, and no one else
except [name of person(s) with access to the information] will have access to the results of the survey.)

DURATION

Your participation in this study will approximately take [State the approximate duration in answering
your instrument]. (Retain if EXPLANATORY SEQUENTIAL or EMBEDDED Design is used: We will contact
you in case there are additional data that we need to ask from you).

RISKS

There are no known risks for you if you decide to participate in this research activity. However, you may
refuse to answer any question or take part if you feel that the question is too personal or if talking about
them makes you uncomfortable.

BENEFITS

The information that will be generated through your participation in this research activity will greatly
help the academe and the society in general. The data that will be gathered will potentially provide
information that will be used in schools as well as program implementers. Please be informed that you
will not receive any remuneration for your participation or reimbursements for expenses incurred as a
result of your participation.

CONFIDENTIALITY

Be assured that the data you will provide the research team will be held with utmost confidentiality. The
data will be stored in secure files and will be disposed of after three years.

SHARING THE RESULTS

The findings of this study will be presented to a panel of experts in our school. There may also be
opportunities for publications or presentation in conferences.
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RIGHT TO REFUSE OR WITHDRAW

Your participation is this research activity is purely voluntary and you have the right to withdraw if you
think you need to do so. Please review your responses, and feel free to make the necessary changes to
your responses, if you think it is necessary.

WHO TO CONTACT

Provide the name and contact information of someone who is involved, informed and accessible - a local
person who can actually be contacted. State also the name (and contact details) of the local RERO that
has approved the proposal.

PART II: CERTIFICATE OF CONSENT

I have read the foregoing information, or it has been read to me. I have had the opportunity to ask
questions about it and any questions I have been asked have been answered to my satisfaction. I
consent voluntarily to be a participant in this study.

Print Name of Participant: _______________________________________________________________

Signature of Participant: ________________________________________________________________

Date: _____________ [MM/DD/YYYY]

If the participant is not able to read or write, a witness must sign (if possible, this person should be
selected by the participant and should have no connection to the research team). Participants who are
incapable of reading or writing should include their thumb print as well.

I have witnessed the accurate reading of the consent form to the potential participant, and the
individual has had the opportunity to ask questions. I confirm that the individual has given consent
freely.

Print name of witness____________ Thumb print of participant:

Signature of witness _____________

Date: ______________ [MM/DD/YYYY]

STATEMENT BY THE RESEARCHER OR PERSON TAKING THE CONSENT

I have accurately read out the information sheet to the potential participant, and to the best of my
ability made sure that the participant understands that the following will be done:

1. He/She will answer the [survey instrument and/or will be interviewed} by the researcher.

2. He/She had been informed, and had consented to participate in this research activity.

I confirm that the participant was given an opportunity to ask questions about the study, and all the
questions asked by the participant had been answered correctly to the best of my ability. I confirm that
the individual has not been coerced into giving consent, and the consent has been given freely and
voluntarily. A copy of this Informed Consent Form has been provided to the participant.
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Print Name of Researcher or Person taking the consent:

_____________________________________________

Signature of Researcher or Person taking the consent:

_____________________________________________

Date: ____________________ [MM/DD/YYYY]