RESEARCH ETHICS REVIEW BOARD

CENTRAL PHILIPPINE UNIVERSITY

Lopez Jaena St., Jaro, Iloilo City, Philippines
329-1971 to 79 local 3336

INFORMED CONSENT FORM (ICF) TEMPLATE

(VERSION No. 03-2023)

INSTRUCTIONS TO THE RESEARCHER/s: This form is required for research involving

surveys, interviews and focus group discussion among adult participants. Obtain an
electronic copy of this form and supply ALL information in the space provided. Do not
change or alter the General statements in BLACK. The words in RED are guide only, after
supplying the correct information delete the words/statements in RED. Explain in terms
understandable to the participants.
Submit this form to researchethics@cpu.edu.ph
Adopted from the WHO & PHREB template.

1. KEY INFORMATION ABOUT THE RESEARCHERS

Title of the Study:

Name of Researcher/s:

Research Adviser:

Department/College:

Institution:

2. INTRODUCTION/BACKGROUND OF THE STUDY

You are invited to take part in this research study. This form contains information
that will help you in deciding whether to participate or not in this study/research.
Before you decide to participate in this study, you will be given enough time to
read and understand the contents of the informed consent. If there are words or
concepts that you do not understand feel free to ask questions at any time, the
researchers are willing to explain it to you and your questions will be answered to
your satisfaction. The study will begin once you have signed the informed
consent form.
This study ________________(provide a brief but concise background of the study)
3. PURPOSE OF THE RESEARCH

The purpose of this research study is to _________________________ (provide a

brief but concise purpose of the study)

4. TYPE OF RESEARCH INTERVENTION/DATA GATHERING INSTRUMENT

The researchers will _____ (discuss the intervention such as the use of data
gathering instrument, conduct of in-depth interview or focus group discussion - that
will be used in your study)

5. PARTICIPANT SELECTION (INCLUSION & EXCLUSION CRITERIA)

You are chosen as a participant based on the following criteria: (enumerate the
inclusion criteria).The following are excluded: (enumerate the exclusion criteria).

6. VOLUNTARY PARTICIPATION

Your participation in this study is entirely voluntary. It is your choice whether to

participate or not. If you choose not to participate or to withdraw from the study at
any time, there will be no penalty or other consequences and without need to give
any reason.

7. PROCEDURE

You will ___________

For interview: Mention the location of the interview & the identity of the interviewer,
describe how the interview will be recorded and kept confidential and explain how
long the study records will be kept and subsequently destroyed.

For questionnaire surveys: Describe how the survey will be distributed and
collected, how the information will be recorded and identity of the participants be
anonymized, who will have access to the results of the survey.
8. DURATION OF THE STUDY

This study will be conducted ___________( state in months and year ( i.e May 2022
to July 2023).

For questionnaire:
You will be given________ (state for how long will it take to answer the
questionnaire).

For interview:
The interview will take __________ (state for how long the interview will take,
assure the participant that if they wish not to answer the question, the interviewer
will move on to the next question)

9. RISKS AND INCONVENIENCES

There is ______________( identify the research related – risk that can be

anticipated and categorized as to: negligible, low, minimal, more than minimal, high
risk) involved in this study. If you are uncomfortable with the questions /procedure
you do not have to answer them/proceed. The researcher will____________
(explain mitigation procedure to manage the risk for the protection of the research
participants’ well-being (Psychosocial, medical, physical support as needed).

10. BENEFITS

This study might help _______(discuss briefly the actual benefits of the study to the
participants, community in which the participants resides, and benefits to society as
a whole).

11. REIMBURSEMENTS

You will _______ (mention any reimbursements or forms of appreciation that will
be provided to your respondents).

12. CONFIDENTIALITY

The information you have provided is solely for the purpose of this study. Your
identity will be kept private and confidential to the extent provided by law. You will
be assigned an ID number and your data will be stored with utmost respect to your
privacy.

13. RIGHT TO REFUSE OR WITHDRAW

Your participation in this study is entirely voluntary. It is your choice whether to

participate or not. If you choose not to participate or to withdraw from the study at
any
time, there will be no penalty or other consequences and without need to give any
reason. If at any time you withdraw from the study, your data will be discarded
properly.

14. DECLARATION OF CONFLICT INTEREST

The researchers declare ___________________(provide a statement of actual or

apparent conflict interest in the conduct of the study).

15. STORAGE AND DISPOSAL OF RESEARCH DATA/MATERIALS

The electronic copy of the data will be kept in a computer that only the researcher(s)
has/have access to. Hard copies will be stored_____ (where) that only the
researcher(s) will have access to for _______ (how long?) and will be disposed
after ____(when) through ____________(how).

16. SHARING OF RESULTS/DISSEMINATION PLAN

The results of this study __________(state the timeline for the sharing of
information, include the details as to how?

As a participant, you are informed that the research findings will be shared more
broadly through publications and conferences.

17. WHO TO CONTACT

If you have any questions or clarifications regarding your participation in the

study, you may contact:

Lead Researcher:__________________________________
Address:_________________________________________
Contact Number:__________________________________
Email address:____________________________________
 If you have questions pertaining to your rights as a participant, you may contact:

Joy G. Raso, PhD.

Chair, CPU Research Ethics Review Board
Email: researchethics@cpu.edu.ph
Phone: 329-1971 (local 3336)

18. CERTIFICATE OF CONSENT

I have read the foregoing information, or it has been read

and explained to me in a language/dialect I know and
understand. 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

Statement by the researcher/person taking consent

I have accurately read out the information sheet to the potential participant,
and to the best on my ability made sure that the participant understands that the
following will be done.
1.
2.
3.
4.
I confirm that the participant was given an opportunity to ask questions about
the study, and all the questions asked by the participant have been answered
correctly and 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.

Print Name of Researcher/person taking the consent________________________

Signature of Researcher/ person taking the consent________________________

Date:_________________
MM/DD/YYYY