Republic of the Philippines

CAVITE STATE UNIVERSITY

Don Severino de las Alas Campus
Indang, Cavite
' (046) 862-1654
www.cvsu.edu.ph

FORM 01. PROTOCOL PACKAGE RECEIPT

STUDY CODE: CvSU-ERB –SSR-2020-00__v1

TITLE: Self-Management Program: It’s Effects on The Psychache Level of the
Students Who Engaged in Non- Suicidal Self- Injury in Cavite State University-
Imus Campus Ay: 2019-2020
PROPONENT: Dago- Oc, Maricah Jomela
Gener, Bianca L.
Sales, Zandrine Nicole V.
Co- Author: Maria Angela L. Diopol, RPsy, LPT

To the principal investigator/research proponent: Kindly arrange the required (with bullets)
and other documents in your protocol package according to the following order. Write NA if
the document is not applicable.

Date Received at ERB with

Original plus 7 copies of the ff.: NA Proponent/Investigator/Representative
and ERB secretariat initials
Endorsement Letter from the research NA
grant if applicable
Accomplished ERB Form 02 -Request for √
Review of Protocol
Accomplished ERB Form 03- Permit to √
Conduct the Study and Informed Consent
(English and Filipino)
Accomplished ERB Form 04 – Ethics √
Review Board Ethical Review Checklist
CV of PI and N/A
Co-investigators/Proponents
GCP and/or Research Ethics Training N/A
Certificate/s
List of study team members with brief job N/A
descriptions
Protocol √
Questionnaire √
Interview guide N/A
Informed Consent in English √
Informed Consent in Filipino N/A
Assent for minors/vulnerable group √
Investigator’s brochure N/A
CDs of Synopsis of Protocol N/A
containing Title, PI, Department,
Sponsor, Primary Objective/s, Brief
Methodology, No. of participants to be
recruited; Study site/s, Duration of study,
Inclusion and Exclusion criteria, Study
Diagram and Flowchart, and Statistical
Analysis and Plan
Analysis and Plan N/A
Agreements/contracts (specify) N/A
Other documents being submitted (specify):

Document Description Version Number Version Date

Please coordinate with the ERB Secretariat should you need clarification regarding your
protocol package’s review track.

Date Submitted:03/10/20 Submitted by: MARICAH DAGO-OC Contact No. 0908-619-9267

Name and Signature

Date Submitted:03/10/20 Submitted by: BIANCA GENER Contact No. 0935-297-9046

Name and Signature

Date Submitted:03/10/20 Submitted by: ZANDRINE SALES Contact No. 0945-782-2735

Name and Signature

Package Received by: ANGIELYN M. ERNI Date:

ERB Secretariat (Name and Signature)

FOR ERB:

REVIEW PACKAGE RECEIVED BY:

_______________________________________________________Date______________
ERB Reviewer/Representative’s Name and Signature

_______________________________________________________Date:______________
ERB Reviewer/Representative’s Name and Signature

_______________________________________________________Date______________
ERB Reviewer/Representative’s Name and Signature

_______________________________________________________Date______________
ERB Reviewer/Representative’s Name and Signature

_______________________________________________________Date______________
ERB Reviewer/Representative’s Name and Signature
 Republic of the Philippines
CAVITE STATE UNIVERSITY
Don Severino de las Alas Campus
Indang, Cavite
' (046) 862-1654
www.cvsu.edu.ph

Form 02. REQUEST FOR REVIEW OF PROTOCOL

Date: March 10, 2020

To : ERB

May I request for the registration, review and approval of protocol entitled:

Self-Management Program: It’s Effects on The Psychache Level of the

Students Who Engaged in Non- Suicidal Self- Injury in Cavite State University-
Imus Campus Ay: 2019-2020

And the other documents checked in the accompanying CvSU ERB Form 01
For the items below, kindly MARK ALL which apply and provide details where applicable.
1. Details regarding the study: To reduce the level of psychache of the participants and their
non- suicidal self- injury and to enhance their self- management behaviors.
(√ ) Social Science Research ( ) Health Science Research
( ) multi-center ( ) multi-national (√ ) Philippines ONLY
(√ ) undergraduate research (√) university research
( ) Graduate thesis/dissertation (√ ) Student’s Requirement
( ) Clinical Trial Phase _____ Involving ( ) Drug ( ) Device ( ) Other _______________
Sponsor/Funding Agency:
Contract Research
Organization:
Are you the author of this ( ) N, I am only implementing this protocol
protocol? (√) Y, this is a self-initiated protocol
2. In connection with this submission I disclose the following:
(√) I have no conflict of interest in any form (financial, proprietary, professional) with
sponsor, the study, co-investigators, nor site
( ) I have personal/family Financial interest in the results of study
Explanation:
( ) I have proprietary interest in the research (patent, trademark, copyright, licensing)
(Indicate nature)
( ) I am connected with the sponsoring agency in my capacity as:______________
3. I am currently involved (as PI) in (Number) studies being conducted at the following sites:
Protocol Title & Sponsor Site Inclusive Dates
N/A N/A N/A
4. I have completed the following research ethics or GCP trainings*:
Training Title Offered by Date
N/A N/A N/A
* Provide proof of attendance
5. I attest to the truthfulness of the entries made in this form.
6. I am submitting 7 copies of the protocol package, along with a protocol summary
containing study diagram & flowchart, and statistical & analysis plan.
Principals Signature Date
Dago-oc, Maricah Jomela 03/10/20
Gener, Bianca L.
Sales, Zandrine Nicole V. 03/10/20

Date Submitted to ERB Study Code: CvSU-ERB-SSR-2020-_______v1

Secretariat:
Title of Study Protocol:
Self-Management Program: It’s Effects on the Psychache of the Students Who
Engaged in Non- Suicidal Self- Injury in Cavite State University- Imus Campus
AY: 2019-2020

Principal Investigator/Proponents:

DAGO-OC, MARICAH JOMELA Student/ CvSU- Imus 03-10-2020

GENER, BIANCA L. Student/ CvSU- Imus 03-10-2020

SALES, ZANDRINE NICOLE V. Student/ CvSU- Imus 03-10-2020

Signature over Printed Name / Designation/ Institution Date

MARIA ANGELA L. DIOPOL, RPSY, LPT Guidance Coordinator, CvSU- Imus 03-10-2020
_________________________________________________________________________
Signature over Printed Name / Designation/ Institution Date

Supervising Investigators/Supervising Researchers:

_________________________________________________________________________
Signature over Printed Name / Designation/ Institution Date

Funding N/A
Agency:
Budget: N/A
Study Site: Cavite State University- Imus Campus
Duration: August 29 - May 2020

Has this protocol/proposal been reviewed by other ERB? ( ) Yes (√ ) No

If yes, name of ERB__________________ ( ) Local ( ) International

If yes, what was the outcome of the review? ( ) Approved ( ) Disapproved

Comment of other ERB

_________________________________________________________________________
FOR ERB USE. DO NOT FILL-UP THIS PORTION

PERMANENT ERB STUDY CODE:

_____________________________________________

[ ] Clinical Drug Trial [ ] General Category [ ] Medical Device []

Study Study Animal/Environm
ent Study
[ ] Bioequivalence [ ] Epidemiological [ ] ART [ ] Genetic Research
/Community
Research
[ ] Traditional [ ] Behavioral [ ] Other Biological [ ] Stem Cell
Medicine Research/Social Material
Research
[ ] Herbal Medicine [ ] Basic [ ] Other (specify)
Science/Health _________________________________
Research _

[ ] IT

ETHICS REVIEW BOARD (ERB): [ ] Approved [ ] Disapproved

No. and Date of ERB Meeting when protocol was initially reviewed/ reported for initial review
(for expedited track): _____________________________________

[ ] Date of Final Approval ______________________________

[ ] Disapproved on Date________________________
If Disapproved, Reason
_________________________________________________________________

Chair, ERB:
________________________
Signature over Printed Name Date
 Republic of the Philippines
CAVITE STATE UNIVERSITY
Don Severino de las Alas Campus
Indang, Cavite
' (046) 862-1654
www.cvsu.edu.ph

Form 03. Informed Consent Approval Sheet

Self-Management Program: It’s Effects on The Psychache Level of the

Students Who Engaged in Non- Suicidal Self- Injury in Cavite State University-
Imus Campus Ay: 2019-2020

Description of the research and your participation

Participants: The research participants for this study are the students of Cavite State
University – Imus Campus who have a high level of psychache.

Risks and discomforts: They are free to choose if they can or cannot participate. If they
choose to participate, but became hesitant due to some unexpected conditions that may
arise, they can withdraw at any time without consequences of any kind.

Potential benefits: The benefit in every participant is the prevention of their non-
suicidal self- injury behaviors and the decrease their psychological pain. The
information also will benefit the university to increase awareness about the issue.

Utilization of the Results of this study: As stated by Promotion in Educational Institutions

of the Mental Health Law, “Educational institutions such as schools, colleges, universities,
and technical schools shall develop policies and programs for students, educators, and other
employees designed to: raise awareness on mental health issues, identify and provide
support and services for individuals at risk,” In line with this, It will serve as a program that
will be utilized by the Guidance and Counseling Office as a preventive measure and
improvement of mental wellness among the students.

Protection of confidentiality: The participants are be identified in the research records by a

code name. The researchers retain the right to use and publish non- identifiable data. When
the results of the research are published or discussed in conferences, no information will be
included that would reveal their identity. All data will be stored in a secure location
accessible only to the researchers.

Voluntary participation: The participation of selected participants is entirely voluntary.

Contact information (Contact Number of Proponent/s and ERB Chairman)

BERNADETTE A. SAPINOSO (046) 862-1654

DAGO- OC, MARICAH JOMELA 0908- 619- 9267
GENER, BIANCA L. 0935- 297- 9046
SALES, ZANDRINE NICOLE V. 0905-749-8011
Co- author: MARIA ANGELA L. DIOPOL, RPsy, LPT 0907- 978- 0509
 A copy of this consent form should be given to you.
Consent

I have read this consent form and have been given the opportunity to ask questions.

I give my consent to participate in this study.

Participant’s signature: ____________________________ Date: ___________

Contact number: _________________________________

Principal Investigator’s signature: ___________________ Date: ___________

Contact number: ___________________________

Approved:
Name: __________________________
Ethics Review Board Chair
Contact number: __________
 Republic of the Philippines
CAVITE STATE UNIVERSITY
Don Severino de las Alas Campus
Indang, Cavite
' (046) 862-1654
www.cvsu.edu.ph

Form 04. Ethics Review Board Ethical Review Checklist

Self-Management Program: It’s Effects on The Psychache Level of the

Students Who Engaged in Non- Suicidal Self- Injury in Cavite State University-
Imus Campus Ay: 2019-2020

PROPONENT/INVESTIGATOR: Dago- Oc, Maricah Jomela

Gener, Bianca L.
Sales, Zandrine Nicole V.
Co - Investigators/Co-Researchers:
Co- Author: Maria Angela L. Diopol, RPsy, LPT
Sponsor:

For the Principal Investigator/Proponent:

This checklist has been prepared to ensure that the protocol submission complies with GCP
standards.

 Please review the checklist carefully.

 In the 2nd column, please indicate the page in the protocol where the item (if
applicable to your study) can be found.
 Write N/A if not applicable.
 Write your other remarks in the column.

For the Reviewer:

 In the 3rd column, please write your remarks.

 Indicate if item is:
o adequately addressed (√)
o not applicable (n/a)
 If the item is not adequately addressed – please write your remarks regarding the
issue which P.I needs to address.
REVIEW of the PROTOCOL

I. Review of the Technical Soundness of To be filled up Remarks by

the Protocol by Principal Reviewer
Investigator/Prop N/A
onents

Page/Paragraph
No.
and
PI’s/Proponents
remarks
1. Were potential conflicts of interest between
the Principal Investigator (PI) /Proponents
and the participant disclosed and √
addressed?
2. Has a scientific/technical review been done
by a research advisory committee?
√
3. Has the protocol been submitted
to/approved by an ERB elsewhere?
a. If yes, please submit the result of N/A
the ERB review elsewhere with the
documents for your present
application.
4. Is there a section on ethical concerns in
the protocol?
√
a. Are possible ethical issues
identified? [gender, culture, equity
(fairness in treating people without √
prejudice)]
b. Is the informed consent process
clearly described?
5. Is the investigator/proponent qualified to
undertake the study?
a. Please submit updated CV of Page 129
investigator (s) and research staff
b. If applicable, please submit certified N/A
true copy of GCP training
certificate.
c. If the study involves patients,
procedures outside the expertise
and/or experience of the
investigator, does the study include
a consultant with the necessary √
qualifications?
6. If the research is collaborative in nature,
are there statements that ensure protection
of: √
a. intellectual property rights
b. publication rights
Is a MOA available/or being executed?
√
7. For studies using a questionnaire or
interview guide,

a. Is the questionnaire developed for Page 37

this study by the proponents?
b. Where is the interview to be N/A
conducted?
c. Is the questionnaire validated? Page 38- 39
d. Where will the respondents answer Page 7-8
the questionnaire?
e. Is the questionnaire approved by √
the advisory committee?
f. Is the source of questionnaire √
cited?
g. Are possible ethical issues
identified in the constructed √
questionnaire? [e.g., gender,
culture, equity (fairness in treating
people without prejudice)
h. Is the Language and tone culturally √
and morally appropriate?
i. Is the Language and tone ethically √
acceptable (non-offensive)? N/A
j. Is there a foreseen risk on the use
of the questionnaire?
k. Is there a foreseen need for a
debriefing session after the √
interview?
l. Is there a provision to assure the √
safety and well-being of the
interviewee?
II. Informed Consent
1. Does the study involve a vulnerable
population? √
2. Are the risks and anticipated benefits
clearly explained? √
3. Is the language and presentation of N/A
information appropriate for the study
population? Is translation from English
required?
4. Is there a faithful translation (not N/A
necessarily literal) of the ICD from English
to the local language?
5. Is the ICD (in the local language) written in N/A
such a way consistent with the Filipino
culture of respect?

For example, the ERB recommends that the

ICD be written in the 2nd person (formal,
polite):
“Kayo po ay inaanyayahang lumahok sa pag-
aaral na pinamagatang “……”. Instead of
“Ikaw ay…. if the subject is an adult).
6. Can individuals make decisions about √
consent under the described conditions?
7. Who will ascertain consent? Is the N/A
presence of third party necessary?
8. Should consent be ascertained periodically
over the course of the study? √

9. Should the IRB monitor the information N/A

provided to potential participants to
determine its sufficiency? Who will
facilitate this?
III. Monitoring and Observation
1. How will the data be recorded and
maintained? √
2. Will researchers be monitoring the
research? Is their plan adequate? Is the √
principal investigator full time on the
project (or there is an appropriate
individual for oversight)?
3. Is there a mechanism for researchers to
update the IRB in the event of unexpected √
developments?
IV. Privacy and Confidentiality
1. Would the research be considered an
intrusion and would individuals be √
offended? Are there ways to reduce this?
Does the aim of the study justify this
intrusion?
2. Will sensitive information (e.g. information
regarding alcohol or drug use; illegal √
conduct; or issue that could lead to social
stigmatization) be collected?
3. Are there sufficient provisions for protection
of confidentiality? Who will have access to √
data?
4. Are researcher’s statements to participants
regarding confidentiality sufficient? √
V. Risk Benefit Analysis
1. Are the risks and anticipated benefits
accurately identified, evaluated, and √
described?
2. Are risks greater than minimal risks?
3. Has attention paid to minimizing risk and
maximizing likelihood of benefits? √
4. Are there adequate provisions for
monitoring risks and benefits? Is a data √
safety monitoring committee required?
VI. Selection of Participants
1. Do participants belong to group that is most
likely to benefit from the research? √
2. Is participant selection justified?
√
3. Will the research pose an unfair burden for N/A
potential participants?
4. Are there procedures to minimize the
pressure on potential participants? √
VII. Recruitment and Incentives
1. Will informed consent be possible given the
recruitment strategies employed? √
2. Are incentives required – given the N/A
demands if participation and the study
population?

Evaluator Only:

How do you rate the risk to participant involved in this study?

( ) Minimal ( ) Moderate ( ) More than moderate ( ) Severe

What is the recommended action on the submitted protocol package?

( ) Approved ( ) with major revision
( ) with minor revision ( ) Disapproved for Resubmission

Signature: ____________________________
Name of Reviewer: ____________________
Date submitted to ERB Secretariat: ________________________________

This protocol was taken up at the (no. of meeting of the ERB on)

NOTE:

A study presents minimal risk if "the probability and magnitude of harm or discomfort
anticipated in the research are not greater in and of themselves than those ordinarily
encountered in daily life or during the performance of routine physical or psychological
examinations or tests."

A study has more than minimal risk (moderate to severe) if as a result of research
participation, the subjects would be exposed to more than a remote possibility of "substantial
or prolonged pain, discomfort, or distress" or "clinically significant deterioration of a medical
condition”
(http://bioethics.georgetown.edu/nbac/capacity/Assessment.htm#Para5, accessed 30 June
2009)

A study with severe risk to participants is disapproved unless there is a strong justification
for the study to be conducted, in which case additional safeguards are recommended.

Guide re Assent Form:

Age of Minor Guidelines

0- less than 7 yrs. Oral assent only meaning the parents are largely
responsible for the child’s response to the procedures to be
done. However, any sign of dissent on the part of the child
(e.g. refusal of a procedure) must be respected.
7 to less than 18 yrs. Oral or Written assent, depending on risk of study. The
study is explained to the child in an appropriate language
taking into consideration the child’s capability to understand
the procedures. Oral assent means that the child does not
sign on the document. Written assent means the participant
signs on the document. Either way, there must be a
statement in the protocol on how the oral or written assent
is to be obtained and documented.
 Republic of the Philippines
CAVITE STATE UNIVERSITY
Don Severino de las Alas Campus
Indang, Cavite
(046) 862-1654
cvsu.edu.ph

Ethics Review Board

Short Description of the Research Proposal

Stud Research Proposal Titles Exempte For For

y No. d Expedite Full
For d Revie
Review Review w
Title: Self-Management Program: It’s Effects on
The Psychache of the Students Who Engaged in
Non- Suicidal Self- Injury in Cavite State University-
Imus Campus Ay: 2019-2020

Background: The researchers are proposed this

study to provide an intervention program for the
students who engaged in non- suicidal self- injury
of Cavite State University-Imus Campus who live
their life with such difficulties that might affect them
negatively. In line with this, the researchers’
created a program entitled, Self-Management
Program (SMP), as a form of intervention which
consists of twelve (12) modules that will utilize the
KSAV and SMART approach and aims to prevent
non-suicidal self-injury behaviors and reduce the
level of psychache of students who engaged in
non- suicidal self- injury in Cavite State University-
Imus Campus.

Objectives: This study aims to assess the

effects of SMP on the level of psychache of the
students who engaged in non- suicidal self- injury
in Cavite State University-Imus Campus AY: 2019-
2020. Specifically, the study aims to:
1. determine the initial level of psychache
of the experimental group A and control
group C;
2. determine the attainment level of
psychache for all experimental and
control groups;
3. determine if there is a significant
difference between the pre-test mean
score and post-test mean scores of
experimental group A in terms of
psychache;
4. determine if there is a significant
difference between the pre-test mean
 score and post-test mean score of
control group C in terms of psychache;
5. determine if there is a significant
difference between the pre-test mean
score of experimental group A and
control group C in terms of psychache;
6. determine if there is a significant
difference between the pre-test mean
score of the control group C and post-
test mean scores of the control group D
in terms of psychache;
7. determine if there is a significant
difference between the post-test mean
score among all groups in terms of
psychache;
1.1 Experimental Group A - Control
Group B;
1.2 Experimental Group A -
Experimental Group C;
1.3 Experimental Group A - Control
Group D;
1.4 Control Group B - Experimental
Group C.

Research Paradigm:

Methodology:

Research Design: The researchers will utilize the

Solomon four-group design which is one of the
three primary designs recommended for use with
true experimental research. This design is a
combination of the pre-test and post- test control
group design and the post-test only design.
Researchers using this design are in a position to
examine both the main effects of testing and the
interaction of testing and treatment. Using the
Solomon four-group design, subjects are randomly
assigned to one of four different groups. Two of the
groups receive the treatment (i.e. intervention) and
two do not (i.e. control). Only one of the treatment
groups is administered the pre-test; however, all
four groups are post-tested.
Population and Sampling: The sampling
technique that the researchers will use is the
simple random sampling technique. In simple
random sampling, the members of the sample are
selected randomly and purely by chance. The
participants of this study are the students who
engaged in non-suicidal self- injury of Cavite State
University-Imus Campus who has high level of
psychache and non-suicidal self-injury behaviors.
The participants will be randomly assigned into four
groups after conducting a needs assessment. The
random assignment will be done by using the
lottery sampling or the fishbowl technique, at least
20 participants for each group. After that, the
researchers will write the numbers of participants in
small pieces of paper, one number in each paper.
Next, the researchers will roll these small pieces of
paper and put them in a container. The researchers
will shake the container thoroughly and will pick
one paper at a time to assign into each group.

Participants: The research participants for this

study are the college students of Cavite State
University–Imus Campus who has high level of
psychache and engaged in non-suicidal self-injury
behaviors. The total participants of this research
are eighty (80), twenty (20) for each control and
experimental group. The researchers chose the
participants in Cavite State University-Imus
Campus because according to a previous study,
78% out of 326 respondents have high levels of
psychache. The Guidance and Counseling Office of
Cavite State University-Imus Campus also have a
significant number of records of students who have
Non-Suicidal Self-Injury behaviors. The
researchers will randomly choose the participants
of each group after conducting a needs
assessment.

Ethical Consideration:
The researchers will ensure that every procedure
that will obtain the needed data is done accordingly
to the code of ethics followed by psychology
professionals, and practitioners. These ethical
considerations helped not only researchers, but the
respondents as well for this gave them an idea
regarding the nature of their participation and rights
as a respondent.

Instrument/s:
The Psychache Scale (Holden et al., 2001)
is a 13-item self-report questionnaire designed to
assess Shneidman's conceptualization of
psychache or psychological pain. Items were
rationally constructed to focus directly on the
 definition of psychache and were written to be
responded to on 5-point scales ranging from either
never to always or from strongly disagree to
strongly agree and explicitly avoid any reference to
suicidality. The Psychache Scale has high reliability
and validity in samples of students and offenders.
The α reliability coefficients of this scale were
generally exceeding 0.90 (Holden et al., 2001; Mills
et al., 2005). Moreover, the Psychache Scale can
successfully tell apart between suicide attempters
and non-attempters (Holden et al., 2001).

Data Gathering Procedure:

To obtain data, the researchers followed several
procedures for this study to be completed

Tools for Gathering Data i.e. interview

schedule, scale, inventory, and the like

Student Researcher/s

MARICAH JOMELA DAGO- OC

GENER, BIANCA L.

SALES, ZANDRINE NICOLE V.

Co- author: MARIA ANGELA L. DIOPOL, RPsy, LPT

Name and Signature
 Adviser Technical Critic

MARIA ANGELA L, DIOPOL, RPsy, LPT PAUL JOHN ESTORNINOS

Name and Signature Name and Signature

Screened by:

DR. BERNADETTE A. SAPINOSO

Chair

Republic of the Philippines

CAVITE STATE UNIVERSITY
Don Severino de las Alas Campus
Indang, Cavite
' (046) 862-1654
www.cvsu.edu.ph

Form 03. Informed Consent Approval Sheet

Self-Management Program: It’s Effects on The Psychache Level of the

Students Who Engaged in Non- Suicidal Self- Injury in Cavite State University-
Imus Campus Ay: 2019-2020

Description of the research and your participation

Participants: The research participants for this study are the students of Cavite State
University – Imus Campus who have a high level of psychache.

Risks and discomforts: They are free to choose if they can or cannot participate. If they
choose to participate, but became hesitant due to some unexpected conditions that may
arise, they can withdraw at any time without consequences of any kind.

Potential benefits: The benefit in every participant is the prevention of their non-
suicidal self- injury behaviors and the decrease their psychological pain. The
information also will benefit the university to increase awareness about the issue.

Utilization of the Results of this study: As stated by Promotion in Educational Institutions

of the Mental Health Law, “Educational institutions such as schools, colleges, universities,
and technical schools shall develop policies and programs for students, educators, and other
employees designed to: raise awareness on mental health issues, identify and provide
support and services for individuals at risk,” In line with this, It will serve as a program that
will be utilized by the Guidance and Counseling Office as a preventive measure and
improvement of mental wellness among the students.

Protection of confidentiality: The participants are be identified in the research records by a

code name. The researchers retain the right to use and publish non- identifiable data. When
the results of the research are published or discussed in conferences, no information will be
included that would reveal their identity. All data will be stored in a secure location
accessible only to the researchers.

Voluntary participation: The participation of selected participants is entirely voluntary.

Contact information (Contact Number of Proponent/s and ERB Chairman)

BERNADETTE A. SAPINOSO (046) 862-1654

DAGO- OC, MARICAH JOMELA 0908- 619- 9267
GENER, BIANCA L. 0935- 297- 9046
SALES, ZANDRINE NICOLE V. 0945- 782- 2735
Co- author: MARIA ANGELA L. DIOPOL, RPsy, LPT 0907- 978- 0509

A copy of this consent form should be given to you.

Consent

I have read this consent form and have been given the opportunity to ask questions.

I give my consent to participate in this study.

Participant’s signature: ____________________________ Date: ___________

Contact number: _________________________________

Principal Investigator’s signature: ___________________ Date: ___________

Contact number: ___________________________

Approved:
Name: __________________________
Ethics Review Board Chair
Contact number: __________