Informed Consent of Students for the Face-to-Face Supervised Pharmacy Practice Experience (SPPE) in

Community Pharmacy During COVID-19 Pandemic

I, _____________, years of age, and a resident of Kita-Kita, Balungao, Pangasinan, consent to undergo
face-to-face SPPE in Community Pharmacy at __________during the COVID-19 pandemic:

a. I understand that COVID-19 is extremely contagious and is spread primarily by person-

to-person contact;

b. I understand that our Dean, ____ & ______Top Management/Owner, Internship

Coordinator and Preceptor have adopted reasonable preventive measures intended
to reduce the spread of COVID-19, but there is still a possibility of transmission as a
result while undergoing SPPE;

c. I understand that our Dean, preceptors, or coordinator may be required to report

COVID-19 related patient information to public health departments, DOH, or the LGU.
For example, if anyone among the student-interns shows symptoms of COVID-19,
disclosure may be necessary for contact tracing or other data collection needs. If
reporting is required, only the minimum necessary information will be disclosed.

1. I agree to take certain precautions which will keep everyone safer from exposure.
a. To minimize exposure, I will:
 Adhere to the safe distancing precautions by keeping a distance of at least 1.5
meters and there will be no physical contact;
 Wear face mask at all times;
 Sanitize frequently my hands by alcohol or alcohol-based hand sanitizer;
 Follow the health and safety protocols implemented in our HTE and in the
___________
b. To notify my Dean, preceptors, or coordinator as soon as possible before reporting to
our HTE premises if I have symptoms of COVID-19 or have been exposed to certain
risk factors.

3. I waive my right to file any complaint against _____, and my College.

I knowingly and willingly consent to undergo face-to-face SPPE in Community Pharmacy at

_________during the COVID-19 pandemic, and I acknowledge the health risk of COVID-19 during this
pandemic. I have read the information provided above and discussed it with our Dean, and all of my
questions have been answered to my satisfaction.

____________________________________________________________ __________________
Signature of Student-Participant/Parent/Legal Guardian Date

______________________________ __________________
Signature of Dean Date

/ncc*C112021/
Revised /sdvm*03142022