Pamantasan ng Lungsod ng Marikina

Senior High School Department

Informed Assent Form for Research Participants

The Informed Assent Statement should be placed so that it can be read out loud to the

respondent before the actual interview begins, preferably on the first page of the

questionnaire, and then the respondent can sign to indicate their consent. In general, the

statement should enable the respondent to indicate that they:

 Agree to participate in the research project.

 Have read the consent statement and the information it contains and had the

opportunity to ask questions about them'

 Agree to their responses being used for education and research on the condition that

their privacy is respected, and that they understand that any personal details may be

included in the research will be used in aggregate form only, so that they cannot be

personally identified;

 Understand the purpose of the research;

 Understand why they were selected to participate (e.g. the nature of their expertise, or

position);

 Understand how they were selected to participate (e.g. randomly or purposive

selection);

 Understand they are under no obligation to take part in the study;

 Understand that they have the right to refuse to answer any questions, or to withdraw

from the study at any stage;

 Understand that the results of the study might be published in a research journal or

book;

 In the case of dissertation research, they should understand that the document will be

available to readers in a university library in printed form, and possibly in electronic

form as well;

Name of Researchers

Research Title

By filling out this questionnaire / answering the questions put to me:

 I agree to participate in this research project;

 I have read this consent form and the information it contains and had the opportunity

to ask questions about them;

 I understand that I was selected to participate in this study due to my expertise,

position and knowledge on the said matter;

 I understand that I was selected purposively from a larger group of people with my

expertise, position and knowledge on the said matter;

 I agree to my responses being used for education and research on condition my

privacy is respected. I understand that my responses will be used in aggregate form

only, so that I will not be personally identifiable;

 I understand that I am under no obligation to take part in this project;

 I understand I have the right to withdraw from this project at any stage;

 I understand that this research might be published in a research journal or book. In the

case of dissertation research, the document will be available to readers in a university

library in printed form, and possibly in electronic form as well;

Name of Participant

(or Guardian if participant is

under 18) :

Signature of Participant

(or Guardian if participant is

under 18) :

Date :
The researcher must supply you with an Information sheet which provides his / her

contact details, outlines the nature of the research and how the information will be

used and explains what your participation in the research involves (e.g. how long it

will take, participants’ roles and rights (including the right to skip questions or

withdraw without penalty at any time), any anticipated risks/benefits which may

arise as a result of participating, any costs or payment involved (even if none, these

should be stated))

Has this been provided? Yes No

Have your received verbal confirmation/explanations where needed? Yes No

Part I. Information Sheet

Introduction

I am J-B Vincent L. Rico, an Accountancy, Business and Management student from

Pamantasan ng Lungsod ng Marikina Senior High School Department, will conduct the

study entitled “ INSERT THE APPROVED TITLE HERE”. The objectives of the

research is/are the following: (1).

Regarding this matter, Indicate your name, what you want to know or what you would

like to happen in this research. I am going to give you the primary information about the

study and invite you. If you are going to participate in the research, your
parent(s)/guardian also have to agree. But if you do not agree to take part in the research,

you do not have to, even if your parents have agreed.

You may talk about anything in this form to your parents, friends or anyone else you feel

comfortable talking to. You can decide whether to participate or not after you have talked

about it. You do not have to decide immediately.

If there are words that you don’t clearly understand or things you want me to explain

elaborately because you are interested or concerned, please don’t hesitate to ask me and I

will take time to explain.

Purpose

Identify the purpose of the research

Participant Selection

Enumerate the inclusive criteria used to identify the participants

Participation is voluntary

Being in this research is voluntary. Just in case you decided to participate, it is highly

appreciated. On the other hand, if you want to quit while other procedure is on-going, we

respect your decision. Your safety is our top priority.

Procedures

Define the procedures needed

Risks

Enumerate the possible risks of the research to the participants

Benefits

Enumerate the possible benefits of the research to the participants

Reimbursements

Confidentiality

Compensation

Sharing the Findings

Right to Refuse or Withdraw

Who to Contact

If you choose to be part of this research I will also give you a copy of this paper to keep

for yourself. You can ask your parents to look after it if there is a need.
 Part II. Certification

CERTIFICATION

I have read this information (or had the information read to me) and I have had my

questions answered and know that I can ask questions later if I have them.

I agree to take part in the research

Print name of child: ___________________________________

Signature of child: ___________________________________

Date: ___________________________________

I do not wish to take part in the research and I have not signed the assent below

If illiterate:

A literate witness must sign (if possible, this person should be selected by the participant,

not be a parent, and should have no connection to the research team). Participants who

are illiterate should include their thumb print as well.

I have witnessed the accurate reading of the assent form to the child, and the individual

has had the opportunity to ask questions. I confirm that the individual has given consent

freely.

Signature over printed name of witness ________________________

Date ________________________
I have accurately read or witnessed the accurate reading of the assent form to the

potential participant, and the individual has had the opportunity to ask questions. I

confirm that the individual has given assent freely.

Print name of researcher ___________________________

Signature of researcher ___________________________

Date ___________________________

Statement by the researcher/person taking consent

I have accurately read out the information sheet to the potential participant, and to

the best of my ability made sure that the child understands that the following will be

done:

1.

2.

3.

I confirm that the child was given an opportunity to ask questions about the study, and all

the questions asked by him/her 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.

  

A copy of this assent form has been provided to the participant.

Signature over printed name of assent administrator _________________________

Date ___________________________

Copy provided to the participant ________ (initialed by researcher/assistant)

Parent/Guardian has signed an informed consent ___Yes ___No _____ (initialed by

researcher/assistant)

References

Retrieved on January 31, 2020 from

http://www.religion.uct.ac.za/sites/default/files/image_tool/images/113/REL

%20Ethics%20-%20Sample%20Consent%20Forms%20-%20for

%20participants.docx

Diño, M. (2014). COMMON MANUAL FOR PUBLICATION AND SCIENTIFIC

STUDIES, First Edition. Marulas, Valenzuela City, Metro Manila, Philippines.

Our Lady of Fatima University. Research Development and Innovation Center.