CVSC-REC Form 5.

1
Republic of the Philippines
Compostela Valley State College
RESEARCH ETHICS COMMITEE
Compostela, Compostela Valley, Philippines 8003
www.cvsc.edu.ph cvsc_rec@cvsc.edu.ph

ETHICS INFORMED ASSENT FORM

(Informed Assent Form for minors or children below 18 years old: do not copy paste the instructions)

Informed Consent Form for ___________________________________

Name of the Researcher(s) ___________________________________
Institution ___________________________________

PART I: INFORMATION SHEET

INTRODUCTION
(Briefly introduce the proponent and concerned organization emphasize that this is an
invitation to participate in a study/research and that he or she can take time to reflect on
whether he or she want to participate or not. Assure the participants that he or she does not
understand some of the words or concepts, that these will be explained and that he or she
can ask question any time)

You are invited to participate in a research study conducted by

____________________, at _______________________ because you fit the inclusion
criteria for informants of our study.

Your participation is completely voluntary. Please read the information below, and ask
question about anything you do not understand, before decide to discuss participation with
your family or friends.

If you decide to participate, you will be asked to sign this form. You will be given a copy
of this form.

PURPOSE OF THE STUDY

Please indicate the purpose of your study. Explain the research question in ordinary, non-
technical terms. Use local and simplified words rather than scientific terms and professional
jargon. Consider local briefs and knowledge when deciding how best to provide the
information.)

STUDY PROCEDURES
(Provide a brief introduction to the format of the research study and in which part of the study
he or she will be involved and explain the type of question that the participants are likely to be
asked, if the research involves question or discussion which may be sensitive or potentially
cause embarrassment, inform the participants of this;
a. For Focus Group Discussion – Give the location for FGD,
b. For interview – inform the participant about the location of the interview. Assure the
participant that he or she does not wish to answer any of the questions during the
interview, the interviewer will move on the next question.
c. For question survey – describe how the survey will be distributed and collected. Infor
the participant that he or she may answer the questionnaire personally. Skipped the
question if the participants don’t want to answer the question and moved on to the next
question. )

DURATION
(Include a statement about the time commitments of the research for the participant including
both duration of the research and follow-up if relevant.
POTENTIAL RISK AND DISCOMFORTS
Example: You may feel discomfort during the course of the interview because of the
sensitive nature of the topic being studied. You may opt not to answer questions which make
you feel any psychological or emotional distress or you can withdraw as a participant of the
study if you feel that you cannot discuss the information that is asked of you. The researchers
value your participation and will place your welfare as their highest priority during the course
of the study.

POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY

(Mention only those activities be actual benefits and not to those to which they are entitled
regardless of participation)

CONFIDENTIALITY
Example: We will keep your records for this study as far as permitted by law. Any
identifiable information obtained in connection with this study will remain confidential, except
if necessary to protect your rights or welfare. This certificate means that the researcher can
resist the release of information about your published or discussed in conferences, no
identifiable information will be used.

PARTICIPATION AND WITHDRAWAL

Example: Your participation is voluntarily. Your refusal to participate will involve no
penalty or loss of benefits to which you are otherwise entitled. You may withdraw your consent
at any time and discontinue participation without penalty. You are not waiving any legal claims,
rights or remedies because of your participation in the research study.

INVESTIGATOR’S CONTACT INFORMATION

Example: If you have any questions or concern about the research, please feel free
to contact the researcher at the _________________________________.

RIGHTS OF RESEARCH PARTICIPANT’S CONSENT

Example: If you have questions, concerns, or complaints about your right as a
research participant or the research in general and are unable to contact the research team,
or if you want to talk to someone independent of the research team, please contact the
___________________________.

PART II: CERTIFICATE OF ASSENT

I have read this information (or had the information read to me) I have had my
questions answered and know that I can ask question later if I have them.

I agree to take part in research.

__________________________________
_________________
Signature above over Printed name of the Child Date Signed

IF ILLITERATE
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.

_____________________________________ ________________
Signature above Printed Name of Participant Date Signed Thumb Print
To be accomplished by the Researcher Obtaining Consent:
I have explained the research to the participant and answered all of his/her questions. I believe
that he/she understands the information described in this document and freely consents to
participate.

_____________________________________ ________________
Name of Person Obtaining Consent Date Signed