TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and
Universities in the Philippines

CONSENT FORM FOR THE FAMILY

Date: November 07, 2022
This informed consent is for the community members of San Agustin, Victoria, Tarlac who we
are inviting to participate in our family case study.
Ma’am Flora Tel-Equen
Clinical Instructor

Greetings!
We are Second Year Student Nurses from Tarlac State University. We are to conduct a
family case study from your community and we would like to invite you to be a part of this
study. This informed consent will be needed today and so we ask you to properly decide first.
Before you decide, you can talk to anyone you feel comfortable with about the research.
This consent form may contain words that you may not understand. Please ask us to stop as
we go through the information and we will take our time to explain. If you have questions
later, you can ask anyone from our group.
In our family case study, we aim to find a household that we can deliver quality care and
interventions to helping that household identify and solve the health problems present in their
surroundings. We believe that you can help us by telling us the common problems that you
experience within the comfort of your home. We want to learn your kind of lifestyle and
living habits that will enable us to look more into how we can deliver our interventions.
This study will take place in a span of 5 weeks every Monday from 7:00 AM to 1:00 PM. In
the duration of the study, we will be visiting your home for about 3 weeks for gathering
information about your household and your living environment. The rest of the weeks would
be for us, the researchers, to finish our paper including the case study for your family. We
would be conducting a group discussion for every week of our assessment and taking pictures
for documentation of your household and your family.
Your participation in this research is entirely voluntary. It is your choice whether to
participate or not. The study being done in the community may draw attention and if you
choose to participate you may be asked questions by other people in the community. Rest
assured we will not be sharing information about you to anyone outside of the research teams.
The information that we collect from this study will be kept private.
With that, we leave the decision making up to you. Thank you!
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and
Universities in the Philippines

Date: November 07, 2022

Statement for the family

I, __________________________________, have read the foregoing information, or it has

been read to me, I have had the opportunity to ask questions about it and any question I have
asked have been answered to my satisfaction. I consent voluntarily to have me and my family
participate in this study.

Printed Name & Signature

Statement for the researcher

We, Group II-A of BSN 2-A from Tarlac State University, have accurately read out the
information sheet to the potential participants, and to the best of my ability made sure that the
participants understand everything with the previous document. I confirm that the participants
were given the opportunity to ask questions about the study, and all the questions asked by
the participants have been answered correctly and to the best of our ability. We confirm that
the consent has been given freely and voluntarily.

FONTANILLA, Bietrize Ysabelle T.

GAMBOA, Viacel G.
GANOTICE, Marron Jane A.
GONZALES, Xyrence P.
GONZALO, Michaella Desiree V.
QUIAMBAO, Ralph P.
REGLOS, Jolo B.