Template for Creating an Informed Consent

Form
This template is for research projects that use questionnaires/surveys, interviews,
focus group discussions, and/or experiments/procedures that involve human
participants.

Note to Researchers:

1.This is a template developed by the Office of Research and Publications Research Ethics
Review Committee (ORP-RERC) to assist research proponents in the design of their
informed consent forms (ICF). Researchers are encouraged to use this when creating
their informed consent forms to best suit the design of their study. Use of alternative
wording or format is allowed.

2.The informed consent form consists of two parts: the information sheet and the consent
section.

3.This guide contains recommended texts and explanations – You do not need to include
these explanations in the informed consent forms that you develop and provide to
participants in your research. Informed consent forms are typically 1-2 pages at most.

4.You may provide the needed information as running paragraphs or under headings, as shown
below.

5.Explanations in italics are for your information and should be deleted from the actual
consent form. Material in brackets should be completed with relevant information.

6.The Informed Consent Form should be signed in 2 copies: 1 for the participant to keep and
1 for the researcher to keep on file.
 [Title of Study]

Informed Consent Form

Name the group for whom this consent form is written. Because research for a single project is often carried
out with a number of different groups of individuals - for example counselors, student leaders, local
government officials - it is important that you identify which group this particular consent is for.

[Name of Principle Investigator]

[Name of Department/Office/Institution]
[Name of Sponsor/Source of Funding]
[Name of Research Project]

Inform participants that they may talk to anyone they feel comfortable talking with about the research and
that they can take time to reflect on whether they want to participate or not. Assure the participant that if
they do not understand some of the words or concepts, that you will take time to explain them as you go
along and that they can ask questions at any time.

PURPOSE OF THE STUDY

You are being invited to take part in a research study. Before you decide to participate in this study, it is
important that you understand why the research is being done and what your participation will involve.
Please read the following information carefully and feel free to ask the researcher if there is anything that is
not clear or if you need more information.
The purpose of the study is to [Briefly explain the research question in layman’s terms which will clarify rather
than confuse. Use local and simplified words rather than scientific terms and professional jargon. In your
explanation, consider local beliefs and knowledge when deciding how best to provide the information.
Indicate why you have chosen this person to participate in this research. People wonder why they have been
chosen and may be fearful, confused or concerned.]

STUDY PROCEDURES

[Provide a clear procedure of the participation in the research study. State what participants will be asked to
do if they choose to participate. List all procedures, preferably in chronological order, which will be
employed in the study.
Explain the type of questions that the participants are likely to be asked in the focus group, interview,
questionnaire, or the survey. If the research involves questions or discussion which may be sensitive or
potentially cause embarrassment or discomfort, inform the participant of this. If the study involves
experiments, the type of procedures that will be undertaken while they participate in the experiment should
be clearly explained. If the participant might experience non-normative bodily sensations, inform them of
this.]

DURATION

[Include a statement about the time commitments of the research for the participant. This includes the
length of time of the interview, FGD, survey questionnaire, or experiment. This should include the duration of
their involvement in the follow-up, if relevant.]

VOLUNTARY PARTICIPATION
Your participation in this study is voluntary. It is up to you whether or not you decide to participate. If you
decide to participate, you will be asked to sign this consent form. After you sign this consent form, you are
still free to withdraw at any time and without giving a reason. Withdrawing from this study will not affect the
relationship you have, if any, with the researcher. If you withdraw from the study before data collection is
completed, your data will be destroyed.

[Indicate clearly that their participation is voluntary and they can choose to participate or not. They can also
withdraw from the study at any time. State that they will still receive all the services they usually do and will
not receive any sanction if they decline participation. If the participant asks, they are entitled to review their
remarks in individual interviews and erase a part or all of the recording or note.]

RISKS

[Explain and describe any risks that you anticipate or that are possible. The risks depend upon the nature of
your study and their participation, and tailored to the specific issue and situation. Provide measures you are
undertaking to minimize the foreseeable risks.]
You may decline to answer any or all questions and you may withdraw your participation at any time if you
choose.

BENEFITS

[Benefits may be divided into benefits to the individual, benefits to the community in which the individual
resides, and benefits to society as a whole as a result of finding an answer to the research question. Explain
the kind of benefit the participant will receive, whether it is a token, gift certificate, expense reimbursement,
education, new knowledge, etc. If there is no direct benefit to the participant, state this. For example: There
will be no direct benefit to your participation in the study. However, we hope that the information from this
study may...]

CONFIDENTIALITY

Your responses in this research will be anonymous. Every effort will be made by the researcher to preserve
your confidentiality, including the following:
[Explain how the research team will maintain the confidentiality of data with respect to both information
about the participant and information that the participant shares. Some measures taken to ensure
confidentiality are listed below:
1.Assigning codes/pseudonyms for participants that will be used on all research notes and
documents
2.Keeping notes, interview transcriptions, and any other personal identifiers in a locked cabinet
that only the researchers will have access to
If the research is sensitive and/or involves participants who are highly vulnerable, explain any extra
precautions you will take to ensure safety and anonymity. For focus groups, provide a particular challenge to
confidentiality because once something is said in the group it becomes common knowledge. Explain to the
participant that you will encourage group participants to respect confidentiality, but that you cannot
guarantee it.]

CONTACT INFORMATION
This study was approved by the Research Ethics Review Committee of DE LA SALLE LIPA. If you have any
questions at any time about this study, or if you experience any non-normative sensations as a result of
participation, you may contact the researcher whose contact information is on the first page. If you have any
questions regarding your rights or treatment as a research participant, or if problems arise during your
participation which you do not feel you can discuss with the Principal Investigator, please feel free to send
an email to orp-rer@dlsl.edu.ph or to call (043) 302-2900 local 1702.

CONSENT
(This section is mandatory]

I have read the provided 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 understand that I will be given a copy of this form, and the researcher will keep
another copy on file. I consent voluntarily to be a participant in this study.

Print Name of Participant____________________

Signature of Participant______________________
Date___________________________________
Day/month/year

(This section is mandatory]

Print Name of Researcher____________________
Signature of Researcher______________________
Date___________________________________
Day/month/year
(This section is optional]
Print Name of Impartial Witness___________________
Signature of Impartial Witness_____________________
Date___________________________________
Day/month/year

(If the participant is illiterate 1]

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__________________________
Signature of witness _________________________
Date
Day/month/year

1 A literate witness must sign (if possible, this person should be selected by the participant and should have
no connection to the research team).