PUP-UNIVERSITY RESEARCH ETHICS CENTER
UREC Form 11
Informed Consent Form No.
Version No. 1
Title of the Research
Study
Researcher/s 1.
2.
3.
Contact Information of the Researcher/s
Cellphone
number
Email address
Background State how the participants/respondents will be recruited.
Purpose of the Study This section must include a brief but complete description
of the research study. The researcher/s must consider
using ‘Lay terms’ to explain this section for easy
understanding.
The researcher/s must also indicate if the data to be
gathered are intended for the thesis/dissertation and must
disclose any potential conflict of interest.
Procedures of the This section must provide a detailed description of the
Study procedures (from how the participants are selected to
what the research study will require including the time
commitment of the participants) so that the participants
will fully understand what they will be asked to do.
Benefits Explain the expected benefits in relation to the subjects
(example: Improvement of oneself). Explain the benefit to
general science or others if applicable.
Risks This section must state all the direct possible risks,
discomforts, and inconveniences to the participants. If
there is any, the researcher/s must state how to mitigate
the identified risks.
In case there aren’t any, the researcher/s must state it as
well.
Cost of Participation This section must clearly state if there are any costs to the
participants for taking part in the research study. If there
aren’t any, this should be clearly stated.
Payment or This section must clearly state if there is any form of
Remuneration remuneration shall be distributed to the participants (i.e.
transportation costs, food allowance, internet load, etc.)
the researchers must clearly state if these amounts will be
pro-rated per research study visit. For research studies
that will employ a prize draw or lotteries, the odds of
winning the prize must be clearly stated. The researcher/s
PUP A. Mabini Campus, Anonas Street, Sta. Mesa, Manila 1016
Trunk Line: 335-1787 or 335-1777
Website: [Link] | Inquiries: [Link]
THE COUNTRY’S 1st POLYTECHNICU
PUP-UNIVERSITY RESEARCH ETHICS CENTER
UREC Form 11
Informed Consent Form No.
Version No. 1
must also include a statement on what will happen to the
compensation in case the participant withdraws from
his/her participation in the study.
Confidentiality This section must clearly state how confidentiality or
anonymity will be achieved or maintained. The
researcher/s must include information on who will have the
access to the data, how, where, and how long it will be
kept, and how it will be disposed of.
The researcher/s must also state how the results of the
study will reach the participants (i.e., through paper
presentation/publication, distribution of soft copy/hard
copy, etc.).
Voluntary Participation This section must state that participation in the research
study is voluntary and that the participants have the
freedom to withdraw from their participation anytime.
The researcher/s must clearly state if in any case that data
withdrawal is possible or not. If data withdrawal is not
possible (at all) or if there is a time duration for the
participants to withdraw from their participation in the
study, there must be a clear statement on how the
communication will be done.
Contact Information:
If you have questions about this research study, or you experience adverse
effects because of participating in this study, you may contact the researcher/s
whose contact information is provided on the first page.
The plan for this research study has been reviewed by the PUP Research Ethics
Committee (PUP-REC). If you have questions regarding your rights as a
research participant, or if problems arise that you do not feel you can discuss
with the researcher/s, please call us at (02) 5335-1787 local 235.
Consent Statement:
I have read and understood the provided information and have had the
opportunity to ask questions. I understand that my participation is voluntary
and that I am free to withdraw at any time, without giving a reason and without
cost. I understand that I will be given a copy of this consent form. I voluntarily
agree to take part in this study.
__________________________________________ __________________
Signature over Printed Name of Participant Date
__________________________________________ __________________
Signature over Printed Name of Researcher Date
PUP A. Mabini Campus, Anonas Street, Sta. Mesa, Manila 1016
Trunk Line: 335-1787 or 335-1777
Website: [Link] | Inquiries: [Link]
THE COUNTRY’S 1st POLYTECHNICU
PUP-UNIVERSITY RESEARCH ETHICS CENTER
UREC Form 11
Informed Consent Form No.
Version No. 1
PUP A. Mabini Campus, Anonas Street, Sta. Mesa, Manila 1016
Trunk Line: 335-1787 or 335-1777
Website: [Link] | Inquiries: [Link]
THE COUNTRY’S 1st POLYTECHNICU
