APPENDIX B: Informed Consent Form

Invitation to Participate
We are JOHN RYAN R. CENTENO and MARY LYN C. MANSALAPUZ, students of the College of
Physical Therapy, Our Lady of Fatima University-Valenzuela. We are currently conducting a study entitled,
“Correlates of Neck Pain and Disability among Medical Technologists: The Effect of Stretching and
Resistance Exercises” as our Special Problem for the degree of Bachelor of Science in Physical Therapy.

You are invited to participate in this research study.

Basis of Subject Selection Commented [o1]: Your study’s inclusion criteria

The reason you are invited is because you are a Registered Medical Technologist, ages 25-59 years old,
working a minimum of 8 hours a day, 5 times a week and having neck pain lasting from 6 to 12 weeks prior
to start of this study.

Purpose of the Study

This study aims to evaluate the effect of stretching and resistance exercises on neck pain and disability
among medical technologists.

Explanation of Procedures Commented [o2]: Very general; must apply for both EG &
You will be asked to participate in an exercise program which will be performed twice a day while at work CG
for a period of 4 weeks. The set of exercises which will be given to you should last only 10 to 15 minutes
per day. You will receive weekly reminder phone calls or emails (from one of the investigators) to remind
you of the suggested exercise frequency. You will also receive a questionnaire from the investigators at the
beginning and every 2 weeks during the course of the study. All you have to do is answer the questions
honestly. The questionnaire will last only 3-5 minutes to accomplish.

Potential Risks and Discomfort Commented [o3]: Be specific about the risks and what
During the tests and exercises, you might experience fatigue; in such instances, you will be allowed to rest the subject must do in case of harm/injury.
and continue the tests/exercises at your own discretion. After the exercises, you might experience soreness
of muscles. You are advised to apply ice pack for 20 minutes on sore muscles for two days. Soreness
generally eases after two days. For any immediate concern, please contact the researchers at the numbers
provided below.

Potential Benefits
You will receive a just compensation (equivalent to your one day allowance) from participating in this
research study. The results of this research study will tell whether stretching and resistance exercises have
significant effect on reducing neck pain and disability among medical technologists. This study will help
physical therapists develop a more comprehensive neck pain & disability evaluation approach and
contribute to the growth of evidence-based physical therapy.

Financial Obligations
All testing and intervention will be provided to you at no cost.

Assurance of Confidentiality
Any information obtained in connection with this research study will be held in strict confidence.

Any information obtained in this research study may be published in appropriate journals or presented at
professional meetings. In such publications or presentations, your identification will be kept strictly
confidential.
Withdrawal from the Study
Participation is voluntary. Your decision whether or not to participate will not affect your present or future
relationship with the researchers. If you decide to participate, you are free to withdraw your consent and to
discontinue participation at any time.

If you have any questions, please do not hesitate to ask. If you think of questions later, please feel free to
contact me at the numbers listed below.

YOU ARE VOLUNTARILY MAKING A DECISION WHETHER OR NOT TO PARTICIPATE IN THIS

RESEARCH STUDY. YOUR SIGNATURE OR THUMBMARK CERTIFIES THAT YOU HAVE
DECIDED TO PARTICIPATE HAVING READ AND UNDERSTOOD THE INFORMATION
PRESENTED. YOUR SIGNATURE OR THUMBMARK ALSO CERTIFIES THAT YOU HAVE HAD
AN ADEQUATE OPPORTUNITY TO DISCUSS THIS STUDY WITH THE INVESTIGATOR AND
YOU HAVE HAD ALL YOUR QUESTIONS ANSWERED TO YOUR SATISFACTION. YOU WILL
BE GIVEN A COPY OF THIS CONSENT FORM TO KEEP.

________________________ ______________
Signature of Subject Date

MY SIGNATURE AS WITNESS CERTIFIES THAT THE SUBJECT SIGNED THIS CONSENT FORM
IN MY PRESENCE AS HIS/HER VOLUNTARY ACT AND DEED.

________________________ ______________
Signature of Witness Date

IN MY JUDGMENT, THE SUBJECT IS VOLUNTARILY AND KNOWINGLY GIVING AN

INFORMED CONSENT AND POSSESSES THE LEGAL CAPACITY TO GIVE INFORMED
CONSENT TO PARTICIPATE IN THIS RESEARCH STUDY.

__________________________ ______________
JOHN RYAN R. CENTENO Date
Lead Investigator
  (+)63927000000 – Mobile