Privacy Statement and Consent to Use of Data

All personal details and documentation related to you (STE student) or your child (SSES pupil)
will be used for the reflection paper as one of the requirements in STS (Science, Technology
and Society) for First Year students enrolled at PUP Cabiao Campus. Interview must be
conducted outside school premises and no classes must be interrupted or whatsoever.

Signing on the space provided below signifies that you are allowing the interviewer to collect
information from you whether in the traditional (note taking) or digital (photo, video, audio) for
the purpose stated above.

Thank you very much!

God bless!

Name of the Interviewer: _______________________________

For the Respondent:

_______________________________________
Signature over printed name

Date of Interview: ______________________

Contact Number: _____________________________________

Email Address: _______________________________________

Noted by:

VINCENT PAUL R. REYES, LPT, MAEd

STS Instructor, PUP Cabiao Campus