St.

Paul University Dumaguete

(St. Paul University System)
L. Rovira Road, Bantayan,
6200 Dumaguete City, Philippines

Informed Consent

PARTICIPATION INFORMED CONSENT FORM

Activity
The Students will hold an interview that would revolve around the theme of “Successful Aging”. They will have
participants consisting of Seniors that would be at least 65 years of age.

Interviewer
This interview is to be conducted by Caintoy, Jonalyn, Dingding, Dynasty, Olivo, Jhona, Selorio, Thea Mae,
Solamillo, Janice, and Tag-at, Joanna, who is pursuing the degree of Bachelor in Science in Nursing at St. Paul
University Dumaguete, with Ms. Sheryl Liz Regis, RN, RM, as the adviser. The interviewer can be contacted
through this mobile number +639185560177 or email address janicesolamillo27@gmail.com

Purpose
This interview is conducted to know the following: (1) to know different perception of older person on how
they age and how would they reflect on themselves (2) to asses how older person have aged successfully.

Potential Benefits
This interview will benefit the (1) Older adults which gives them the chance for self-exploration. This form of
interview allows them to explore who they are and what they value. They can reflect on their life and discover
how aging has affected their sense of self., (2) Significant others which help them to know how older adults
think because what they feel might dictate pretty much their entire perception of reality, with this, it will help
them understand each other, know potential problems and develop a stronger relationship.

Confidentiality
No information revealing your identity will be made public or disclosed without your explicit authorization and
only when absolutely necessary. After information processing within a predetermined time frame, the
materials that included the raw information collected from you will be destroyed.

Participation
This activity shall not be forced upon you since this interview is very much voluntary in nature. Should you
ever feel uncomfortable at any point of the activity and want to withdraw, then you may do just that  as it is
your right to do so. It is rest assured, that any information that was gathered until at the point of withdrawal
will be kept confidential and be erased accordingly.
 St. Paul University Dumaguete
(St. Paul University System)
L. Rovira Road, Bantayan,
6200 Dumaguete City, Philippines

Informed Consent

Given the information above, I confirm that the potential harms, benefits, and alternatives have been
explained to me. I have read and understand this consent form, and I understand that I am free to
withdraw from my involvement in interview any time I deemed it be necessary or to seek
clarifications for any unclear steps in the interview process. My signature indicated my willingness to
participate in the said interview.

ROSARIO M. SELORIO April 02, 2023 @ 9 am

PRINTED NAME AND SIGNATURE OF THE PARTICIPANT DATE AND TIME

+63 (035) 225-1506 Local 218 to 219 https://www.spud.edu.ph/

+63 (035) 420-6499 spudgte@gmail.com
spudcollegenursing@gmail.com Accreditation and Certifying Bodies
+63 (035) 225-7217