EMILIO AGUINALDO COLLEGE

Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 [Link]
RESEARCH AND DEVELOPMENT OFFICE

 Informed Consent Form

 Research Tool or Instrument
 Sample Letter to Concerned Individuals/Institutions

Received and Verified by:

Research Office: __________________ Date: ________________

For Researcher/s ERC Findings and

Questions YES NO Remarks Comments
1. Does the Research Proposal Yes, this research
involve human participants? If proposal does involve
YES, describe. human participants,
specifically drivers who
share the road with e-bike
users.
2. Will the research be conducted No, the research will
in an institution, business not be conducted in an
establishment, government institution, business
agency, and the like? If YES, establishment, or
please identify and provide government agency.
copy of Letter of However, we will
Intent/Permission to conduct coordinate with and seek
research in that institution. permission from the
barangay authorities to
ensure our safety and
access to necessary
information during the
study. A letter will be
provided to confirm this
coordination.
3. Does the research include an
Informed Consent Form? If Yes, the researcher
YES, provide a copy. provided an informed
consent form.

4. Does the Informed Consent Yes, the informed

Form indicate that the consent document will
individual is invited to invite individuals to
participate in the research participate in a research
which is being undertaken by study, providing the
the researcher from an institution’s name, study
institution? objectives, and
confirmation of its
commitment to
transparency, trust, and
ethical standard.
QF-RDO-016 (03.19.2024) Rev.06
5. Does the Informed Consent Yes, the form will
Form state the reasons for clearly state that
considering the individual participation is entirely
suitable for the study, and that voluntary, ensuring
participation is voluntary? participants understand
they can choose whether
to participate and that
they may withdraw at any
time.
6. Does the Informed Consent Yes, the informed
adhere to the principles of consent form adheres to
transparency, legitimate the principles of the Data
purpose, and proportionality in Privacy Act of 2012,
the collection, retention, and which include
processing of personal transparency, legitimate
information (Data Privacy Act of purpose, and
2012)? proportionality.
7. Does the Informed Consent Yes, the informed
Form state that the individual is consent form promotes
free to refuse to participate in ethical standards in
the research without penalty or research and ensures
loss of benefits to which he or that participants are fully
she is entitled? aware of their rights
regarding participation.
8. Does the Informed Consent Yes, the informed
Form state the purpose of the consent from ensure
research, the procedures to be ethical standards are met
carried out by the researcher, and that participants are
and an explanation of how the fully informed,
research differs from routine empowering them to
medical or health care? make knowledge
decisions about their
participation in the
research.
9. Does the Informed Consent
No, the informed
Form describe any foreseeable
consent from does not
risks, pain or discomfort, or
adequately address
inconvenience to the individual
important information
(or others) associated with
regarding potential risk
participation in the research,
associated with
including risks to the health or
participation in the
well-being of the individual’s
research.
spouse or partner or family?
10. Do the participants involve No, the participants do
children below 18 years of not include children below
age? If YES, provide a copy of 18 years of age. Only
Parental Consent. adult participants,
specifically licensed
drivers, will be involved in
the study.
11. Does the research have a Yes, The researcher
Research Tool or Research provided a copy of
Instrument that will be given to research tool or research
the participants? If YES, instrument.
QF-RDO-016 (03.19.2024) Rev.06
 provide a copy.
12. Does the research have a No, this research does
Letter seeking permission to not include a letter
conduct research in an seeking permission to
institution, business conduct from an
establishment, government institution, business
agency, or the like? If YES, establishment, or
provide a copy. government agency.
However, there was a
letter submitted to the
barangay to seek
permission for conducting
the research and to
ensure the safety of the
research team.
13. Is there a possibility that the
research participants will No, the research
experience physical or participants will not
psychological harm? If YES, experience physical and
justify how the benefit psychological harm.
outweighs the harm.
14. Will the research involve the
administration of drugs of any
kind to the participants? If YES, No, the study have not
justify how the benefit involve any kind of drugs
outweighs the harm, and how to the participants.
the participants would be able
to go back to their normal state
prior to the research.
15. Does the research involve No, the research does
extraction of bodily fluids? If
not involve any extraction
YES, describe the procedure
and how they will be disposed of bodily fluids.
of.
16. Does the research involve
No, the research do not
genetic study? If YES, describe
involve any genetic study.
procedures and preservation of
confidentiality.
17. Will the research cause No, the participants will
participants to spend? If YES, not spend in participation
describe how you would make in this study.
it acceptable to them.
18. Is there a possibility that the No, there is no concern
results of the research will that the findings of this
cause harm to the reputation of study will negatively
the participants or even to the impact the reputation of
community where they come the participants. The
from? If YES, describe how you inclusion of names in the
can ensure confidentiality and questionnaire provided by
anonymity. the researchers is entirely
optional.
19. Is the research relevant to an Yes, this research
existing social or health addresses a relevant
social and health issue.
QF-RDO-016 (03.19.2024) Rev.06
 problem such that the results With the rising popularity
are expected to bring about a of e-bikes, there is an
better understanding of related increased need to
issues, or contribute to the understand safety
promotion of well-being of concerns and perceived
individuals, their families, and risks on the road, as
conflicts between drivers
communities? If YES, describe.
and e-bike users can
impact public safety and
traffic harmony.
The study provides
insights into driver
perceptions of e- bike
users, information policy
adjustments, road-
sharing strategies, and
educational initiatives to
promote safer road
interactions. Ultimately, it
aims to reduce accidents
and enhance overall road
safety for individuals and
communities.
20. Will the research design,
methodology, and data Yes, the research
collection be able to generate design, methodology, and
information supportive of the data collection have been
objectives of the study to make developed to ensure
it scientifically valid? scientific validity and
support the study’s
objectives.

21. Is the research relevant to an Yes, this research

existing social or health addresses a relevant
problem such that the results social and health issue.
are expected to bring about a With the rising popularity
better understanding of related of e-bikes, there is an
issues, or contribute to the increased need to
promotion of well-being of understand safety
individuals, their families, and concerns and perceived
communities? If YES, describe. risks on the road, as
conflicts between drivers
and e-bike users can
impact public safety and
traffic harmony.

The study provides

insights into driver
perceptions of e-bike
users, information policy
adjustments, road-
sharing strategies, and
educational initiatives to
promote safer road

QF-RDO-016 (03.19.2024) Rev.06

 interactions. Ultimately, it
aims to reduce accidents
and enhance overall road
safety for individuals and
communities.
22. Will the research design, Yes, the research design,
methodology, and data collection methodology, and data
be able to generate information collection have been
supportive of the objectives of the developed to ensure
study to make it scientifically scientific validity and
valid? support the study’s
objectives.
23. Does the research protocol justify Yes, the protocol
the need for the study, that is, why effectively justifies
the study shall be conducted given conducting the study,
the current state of knowledge? establishing its relevance
and importance in
advancing understanding
or practical applications in
the field.
24. Does the research protocol
establish the appropriateness of Yes, the protocol
the proposed methods for demonstrates that the
investigating the research chosen methods are not
problem? only appropriate but also
methodologically rigorous
for investigating the
research problem.
25. Does the research protocol No, it does not provide
provide evidence for the feasibility strong evidence for
of doing the study as proposed, feasibility, raising
that is, that the study can be concerns about whether
completed successfully in the
the study can be
specified time and with the
available resources? completed successfully
as proposed.
26. Does the research protocol
describe the recruitment process Yes, the protocol
(where, who, how)? demonstrates a well-
thought-out recruitment
process that supports the
study's feasibility and the
likelihood of obtaining a
representative sample.
27. Does the research protocol
describe the dissemination plan for Yes, the protocol
research results and outcomes? demonstrates a clear plan
for ensuring that research
findings reach and benefit
relevant audiences.

QF-RDO-016 (03.19.2024) Rev.06

 28. Does the research protocol
describe the purpose of the study, Yes, the protocol
the design, the population, the demonstrates a well-
methods of data collection, and structured approach to
the planned analyses? conducting the study,
providing clarity on each
step from purpose to
analysis.
29. Does the research protocol Yes, the protocol
describe treatment of data and shows that it has carefully
confidentiality of information if data considered the ethical
collection will come from datasets
and legal implications of
of institution, business
establishment, government
using institutional or
agency, and the like? agency data, ensuring
participant privacy and
data security throughout
the study.

Accomplished by:

Team Roque
Researcher
Date: _____________________________

COMMENTS/SUGGESTIONS/RECOMMENDATIONS:
(For ERC Use Only)

Validated and Evaluated by:

__________________________________
Member, Ethics Review Committee
Date: _____________________________
QF-RDO-016 (03.19.2024) Rev.06