Pamantasan NG Lungsod NG Marikina: Senior High School Department

Pamantasan ng Lungsod ng Marikina
Senior High School Department
Informed Assent Form for Research Participants
The Informed Assent Statement should be placed so that it can be read out loud to the
respondent before the actual interview begins, preferably on the first page of the
questionnaire, and then the respondent can sign to indicate their consent. In general, the
statement should enable the respondent to indicate that they:
 Agree to participate in the research project.
 Have read the consent statement and the information it contains and had the
opportunity to ask questions about them'
 Agree to their responses being used for education and research on the condition that
their privacy is respected, and that they understand that any personal details may be
included in the research will be used in aggregate form only, so that they cannot be
personally identified;
 Understand the purpose of the research;
 Understand why they were selected to participate (e.g. the nature of their expertise, or
position);
 Understand how they were selected to participate (e.g. randomly or purposive
selection);
 Understand they are under no obligation to take part in the study;

 Understand that they have the right to refuse to answer any questions, or to withdraw
from the study at any stage;
 Understand that the results of the study might be published in a research journal or
book;
 In the case of dissertation research, they should understand that the document will be
available to readers in a university library in printed form, and possibly in electronic
form as well;
Name of Researchers
Research Title
By filling out this questionnaire / answering the questions put to me:
 I agree to participate in this research project;
 I have read this consent form and the information it contains and had the opportunity
to ask questions about them;
 I understand that I was selected to participate in this study due to my expertise,
position and knowledge on the said matter;
 I understand that I was selected purposively from a larger group of people with my
expertise, position and knowledge on the said matter;

 I agree to my responses being used for education and research on condition my
privacy is respected. I understand that my responses will be used in aggregate form
only, so that I will not be personally identifiable;
 I understand that I am under no obligation to take part in this project;
 I understand I have the right to withdraw from this project at any stage;
 I understand that this research might be published in a research journal or book. In the
case of dissertation research, the document will be available to readers in a university
library in printed form, and possibly in electronic form as well;
Name of Participant
(or Guardian if participant is
under 18) :
Signature of Participant
(or Guardian if participant is
under 18) :
Date :
The researcher must supply you with an Information sheet which provides his / her
contact details, outlines the nature of the research and how the information will be
used and explains what your participation in the research involves (e.g. how long it
will take, participants’ roles and rights (including the right to skip questions or
withdraw without penalty at any time), any anticipated risks/benefits which may
arise as a result of participating, any costs or payment involved (even if none, these
should be stated))
Has this been provided? Yes No
Have your received verbal confirmation/explanations where needed? Yes No
Part I. Information Sheet
Introduction
I am J-B Vincent L. Rico, an Accountancy, Business and Management student from
Pamantasan ng Lungsod ng Marikina Senior High School Department, will conduct the
study entitled “ INSERT THE APPROVED TITLE HERE”. The objectives of the
research is/are the following: (1).
Regarding this matter, Indicate your name, what you want to know or what you would
like to happen in this research. I am going to give you the primary information about the
study and invite you. If you are going to participate in the research, your
parent(s)/guardian also have to agree. But if you do not agree to take part in the research,
you do not have to, even if your parents have agreed.
You may talk about anything in this form to your parents, friends or anyone else you feel
comfortable talking to. You can decide whether to participate or not after you have talked
about it. You do not have to decide immediately.
If there are words that you don’t clearly understand or things you want me to explain
elaborately because you are interested or concerned, please don’t hesitate to ask me and I
will take time to explain.
Purpose
Identify the purpose of the research
Participant Selection
Enumerate the inclusive criteria used to identify the participants
Participation is voluntary
Being in this research is voluntary. Just in case you decided to participate, it is highly
appreciated. On the other hand, if you want to quit while other procedure is on-going, we
respect your decision. Your safety is our top priority.

Procedures
Define the procedures needed
Risks
Enumerate the possible risks of the research to the participants
Benefits
Enumerate the possible benefits of the research to the participants
Reimbursements
Confidentiality
Compensation
Sharing the Findings
Right to Refuse or Withdraw
Who to Contact
If you choose to be part of this research I will also give you a copy of this paper to keep
for yourself. You can ask your parents to look after it if there is a need.
Part II. Certification
CERTIFICATION
I have read this information (or had the information read to me) and I have had my
questions answered and know that I can ask questions later if I have them.
I agree to take part in the research
Print name of child: ___________________________________
Signature of child: ___________________________________
Date: ___________________________________
I do not wish to take part in the research and I have not signed the assent below
If illiterate:
A literate witness must sign (if possible, this person should be selected by the participant,
not be a parent, and should have no connection to the research team). Participants who
are illiterate should include their thumb print as well.
I have witnessed the accurate reading of the assent form to the child, and the individual
has had the opportunity to ask questions. I confirm that the individual has given consent
freely.
Signature over printed name of witness ________________________
Date ________________________
I have accurately read or witnessed the accurate reading of the assent form to the
potential participant, and the individual has had the opportunity to ask questions. I
confirm that the individual has given assent freely.
Print name of researcher ___________________________
Signature of researcher ___________________________
Date ___________________________
Statement by the researcher/person taking consent
I have accurately read out the information sheet to the potential participant, and to
the best of my ability made sure that the child understands that the following will be
done:
1.
2.
3.
I confirm that the child was given an opportunity to ask questions about the study, and all
the questions asked by him/her have been answered correctly and to the best of my
ability. I confirm that the individual has not been coerced into giving consent, and the
consent has been given freely and voluntarily.

A copy of this assent form has been provided to the participant.
Signature over printed name of assent administrator _________________________

Date ___________________________
Copy provided to the participant ________ (initialed by researcher/assistant)
Parent/Guardian has signed an informed consent ___Yes ___No _____ (initialed by
researcher/assistant)
References
Retrieved on January 31, 2020 from
http://www.religion.uct.ac.za/sites/default/files/image_tool/images/113/REL
%20Ethics%20-%20Sample%20Consent%20Forms%20-%20for
%20participants.docx
Diño, M. (2014). COMMON MANUAL FOR PUBLICATION AND SCIENTIFIC
STUDIES, First Edition. Marulas, Valenzuela City, Metro Manila, Philippines.
Our Lady of Fatima University. Research Development and Innovation Center.

Pamantasan NG Lungsod NG Marikina: Senior High School Department

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Pamantasan ng Lungsod ng Marikina

Senior High School Department

Informed Assent Form for Research Participants

statement should enable the respondent to indicate that they:

 Agree to participate in the research project.

opportunity to ask questions about them'

 Understand the purpose of the research;

 Understand how they were selected to participate (e.g. randomly or purposive

 Understand they are under no obligation to take part in the study;

from the study at any stage;

available to readers in a university library in printed form, and possibly in electronic

By filling out this questionnaire / answering the questions put to me:

 I agree to participate in this research project;

to ask questions about them;

 I understand that I was selected to participate in this study due to my expertise,

position and knowledge on the said matter;

expertise, position and knowledge on the said matter;

privacy is respected. I understand that my responses will be used in aggregate form

only, so that I will not be personally identifiable;

 I understand that I am under no obligation to take part in this project;

case of dissertation research, the document will be available to readers in a university

library in printed form, and possibly in electronic form as well;

(or Guardian if participant is

(or Guardian if participant is

Has this been provided? Yes No

Have your received verbal confirmation/explanations where needed? Yes No

Part I. Information Sheet

I am J-B Vincent L. Rico, an Accountancy, Business and Management student from

research is/are the following: (1).

you do not have to, even if your parents have agreed.

about it. You do not have to decide immediately.

will take time to explain.

Identify the purpose of the research

Enumerate the inclusive criteria used to identify the participants

respect your decision. Your safety is our top priority.

Define the procedures needed

Enumerate the possible risks of the research to the participants

Enumerate the possible benefits of the research to the participants

Sharing the Findings

Right to Refuse or Withdraw

I agree to take part in the research

Print name of child: ___________________________________

Signature of child: ___________________________________

are illiterate should include their thumb print as well.

Signature over printed name of witness ________________________

confirm that the individual has given assent freely.

Print name of researcher ___________________________

Signature of researcher ___________________________

Statement by the researcher/person taking consent

consent has been given freely and voluntarily.

A copy of this assent form has been provided to the participant.

Signature over printed name of assent administrator _________________________

Copy provided to the participant ________ (initialed by researcher/assistant)

Parent/Guardian has signed an informed consent ___Yes ___No _____ (initialed by

Retrieved on January 31, 2020 from

Diño, M. (2014). COMMON MANUAL FOR PUBLICATION AND SCIENTIFIC

STUDIES, First Edition. Marulas, Valenzuela City, Metro Manila, Philippines.

Our Lady of Fatima University. Research Development and Innovation Center.

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Parent/Guardian has signed an informed consent _Yes _No _____ (initialed by