INFORMED CONSENT

The research program in Sustainable Organ Donation and Transplantation R & D Center aimed at
Increasing Identification of Potential Organ Donors with moderate-severe brain injury through
an Electronic Medical Record-Donor Alert System (EMR-DAS) integrated Response. This study will
be done in Southern Philippines Medical Center for two (2) years, and will include all patients
admitted at the Emergency Room with a devastating brain injury. The study will make purposive
sampling and will include all patients that will meet the criteria for the duration of two (2) years.

All data gathered in this study is strictly confidential and will be only shared with the investigators
for the study. All pertinent data privacy laws will be applied to the data gathered.

I am aware that I or my patient will be added to the study as it is an automated system. I am

giving my consent voluntarily that my or my patient’s data will be used in this study.

Yes, I will consent to my data to be used in the study

No, I will not consent to my data to be used in the study

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Printed Name over Signature Date

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Relationship to the patient