BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

Informed Consent for Participating in the Physical Assessment and MMDST of a Child

Purpose and Procedure: This data gathering activity being conducted by Level 2 students of the
College of Nursing of Bulacan State University will help the students in gaining deeper
understanding about their subject NCM104/ Community Health Nursing. It will further enhance
their skill in conducting physical assessment, and performing Metro Manila Developmental
Screening Test. You and your child will be asked to participate in a physical assessment and a
short test of some skills that your child can perform considering his/her age. The entire process
will take approximately 30-45 minutes to complete.

Voluntary Participation: Your participation in this data gathering activity is completely voluntary
and you may choose to stop participating at any time.

Risks and Benefits: There is no direct benefit to you for participating in this data gathering
activity, instead the information you will give will help the student experience the activity of
their course in this time of pandemic. The data collected will be used for educational purposes
only.

Withdrawal from the Study: You can stop participating in this data gathering at any time, for any
reason, if you so decide. Your decision to stop participating, or to refuse to answer any of the
questions, will be highly regarded.

Anonymity: All answers you provide in the survey will not be linked to your name and rest
assured that all information gathered will be used for studying purposes. Your answers will be
tag as strictly confidential.

Who to Contact: If you have questions about the data gathering procedure, please feel free to
contact Ms.------------------------------Class Adviser by e-mail --------------- and/or Mrs. Rhealeen
V. Vicedo, Level II Coordinator by e-mail at rhealeen.viray@bulsu.edu.ph or mobile
09285031645.

Legal Rights and Signatures:

I_________________________, consent to participate in the above mentioned data gathering

activity conducted by Level II students of the College of Nursing of Bulacan State University. I
have understood the nature of this activity and wish to participate. My signature below indicates
my consent and will not be linked to my answers.

Participant Signature:____________________ Signature Date_____________________

Witness Signature: _____________________ Signature Date_____________________