Republic of the Philippines

Mindanao State University

Marawi City

COLLEGE OF EDUCATION

Consent Form

Part I. Information Sheet

Dear Respondents (You can specify here if your respondents/participants are Pre-
service teachers, parents, Teachers, Pupils, etc.):

Greetings of peace.

We, _____________________________________and _________________________________, a

(Course) students at Mindanao State University – Marawi Campus. We are the
principal investigators of this study entitled:
“________________________________________________________________________________
_________________________________________________________________________________
__________________________________________”. The main objective of this study is to
(state your objective/s here). We are respectfully requesting your voluntary
participation in this study and to give consent to take part as respondent/participant
of this research. All the information you put into will remain confidential. Please take
time to go over this consent form and feel free to consult or discuss it with your family,
relatives or friends. If you agree to participate, please affix your name and signature
on this form and if you wish to have a copy of this form, we will be pleased to hand
you a personal copy. There may be some words you don't understand or things that
you want me to explain more about because you are interested or concerned.
Please do not hesitate to approach me.

Purpose
The purpose of this study is to (state your purpose here)

Participants
The study will particularly use the (specify the sampling method with detailed
steps and the final sample size)

Duration
The duration of this survey/interview will run from (specify range of minutes to
consume). Thereafter the submission of the (specify the research instrument), if there
are some gaps or missing information, you may be asked for a brief clarificatory
interview session of not more than (specify range of minutes to consume).

Risks
Rest assured there are no sensitive issues in this (specify the research
instrument). Should there be any questions that you are not comfortable answering,
you are free to tell the researcher about it so the item will be skipped or avoided.

Benefits
This study attempts to contribute to (specify the significance of the study)

Withdrawal
While the principal investigators wish for you to complete the
(survey/interview/assessment) ___________, your participation is voluntary. As such, you

CEDREC-ConFormPair
 Republic of the Philippines
Mindanao State University
Marawi City

COLLEGE OF EDUCATION
have the right to withdraw your participation at any time throughout
the__________________.

Confidentiality:
Your participation in this research is strictly confidential. Only members of the
research team will have access to the information associated with this study. The data
will be stored, secured and locked in (specify the location), while the e-file of your
information will be kept in a password-protected computer. Any information related
to this study and identified with you will remain confidential and will be disclosed only
with your permission or as required by law. Your name or identity will not appear in the
results and discussion of this research. The researchers will only use pseudonyms in case
of direct quotations. Rest assured that utmost care and precautions are observed to
ensure safety and anonymity of the participants’ information except for any untoward
events that are beyond the control of the researchers and the research team.

Sharing The Results

The research findings will be presented to the Thesis Panel Committee. Once
approved, copies of the manuscript will be shared with each member of the
committee, the main and unit library, CED Archive Room and CED Research Office.

As a future undertaking, the researchers also intend to publish the research

paper in the legitimate publication journals and conferences, of local or international
setting.

Contact
If you have further questions or concerns about your rights as a
respondent/participant in this study, contact the principal investigators at (input your
mobile number) or at (email address). You also reach out to my Thesis Adviser (Prof,
Dr.____) through the following contact details, (specify mobile number and email
address). Thank you for your time.

We are requesting your cooperation and consideration in this study. I humbly ask that
you take your time in participating in this research study. Thank you very much! God
bless you.

Sincerely,

Printed Name and signature

Researchers

CEDREC-ConFormPair
 Republic of the Philippines
Mindanao State University
Marawi City

COLLEGE OF EDUCATION

Part II. Certificate of Consent

I have read and understood the background information that you have provided
about your research. I recognize the possible demands this research study requires
and thus, I volunteer to take part in the research. My participation is subject to the
following conditions:

1. The adequate security will be provided to maintain the privacy and

confidentiality of my responses.
2. That there will be no personal identifiers from the result of the study.
3. That I can withdraw my participation from your study anytime for personal
reasons.
4. That my test results become part of College of Education, MSU-Marawi
Campus. Release of such information may be obtained only with prior
approval of the research proponent/s.

☐ I HEREBY AGREE to be one of the respondents/participants in the said research

only.
☐ I DO NOT AGREE to be one of the respondents/participants in the said research
only.

Print Name of Participant/Respondent: _____________________________

Signature of Participant: ______________________________

Date: [MM/DD/YYYY]

If Illiterate
A literate witness must sign (if possible, this person should be selected by the
participant and should have no connection to the research team). Participants who
are illiterate should include their thumb print as well.

___________________________________________________
Name and Signature of a literate witness

Thumb mark of participant,

if illiterate.

______________________________________________
Name and Signature of the Person Taking the Consent
(Pangalan at Lagda ng Taong Kumukuha nang Pahintulot)

CEDREC-ConFormPair