Form D Informed Consent Assessment Form: University of Mindanao Ethics Review Committee

UMERC– 004
University of Mindanao
Rev. 01 / December 1, 2016
Form D Approved by:
Informed Consent Assessment Form Control No.: _______________
University of Mindanao Ethics Review Committee

Matina, Davao City
IMPORTANT: All fields must be completed.
Research Title: Teacher Behavior and Student Attitude towards English

Language Learning
Researcher: Phee May P. Diel
Date Submitted: September 11, 2019

Date Received: _________________________
C NC N/A
1 Informed consent form is attached /
2 The information sheet is free of technical terms, is written in lay-persons’ /
language, and is easily understandable, complete, and adequate
3 The proposal makes it clear that the proposed study is research /
4 The proposal explains the purpose of the study and the justification of the /
participants’ eligibility in participating in the study
5 The proposal clearly states the period to accomplish the study /
6 The proposal provides the participants full description of the nature, /
sequence and frequency of the procedures to be carried out
7 The protocol provides a description or explanation as to the nature and /
likelihood of anticipated discomfort or adverse effects, including psychological
and social risks, if any and what has been done to minimize these risks, and
the action to be taken if they occur
8 The proposal describes/ enumerates the possible benefits, if any, to the /
research participants
9 The proposal describes/ enumerates the possible benefits, if any, to the /
community or to society
10 The proposal describes/ enumerates the procedure that will be followed to /
protect the confidentiality of participants’ data (either that provided by
participants or that derived during and from the research itself
11 The proposal contains a description conveying to a participant that /
confidentiality is waived due to the research design of the study
12 Provisions on voluntary participation, which include the participants are free /
to decide not to participate, refusal to participate (or discontinue
participation) with no penalty or loss of medical benefits to which they are
otherwise entitled to
13 The proposal provides a description of the nature of any compensation or /
reimbursement to be provided (in terms of time, travel, man-days lost from
work, etc.)
14 The proposal includes other options of participation /
15 The proposal provides the description of procedure that will be followed to /
keep the participants informed of the progress and outcome of the research
16 The proposal includes the contacts such as the name and contact details of a /
person who can provide more information about the research projects at any
time
17 Provisions on participants/ subjects incapable of reading and signing the /
UMERC– 004
University of Mindanao
Rev. 01 / December 1, 2016
Form D Approved by:
Informed Consent Assessment Form Control No.: _______________
written consent form (e.g. illiterate patients) (Please explain on another

sheet/s of paper)
18 Provision describing incapability of participants to giving personal consent
(e.g. because of cultural factors, children or adolescents less that the legal /
for consent in the country in which the research is taking place, participants
with mental illness, etc.) to express their decision. (Please explain on
another sheet/s of paper)
19 The consent certificate includes the statements “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 participate as a subject in this study and
understand that I have the right to withdraw from the study at any time
without in any way it is affecting my person or reputation.”
Legend: C – Complied NC – Not Complied N/A – Not Applicable
Submitted by:
Name Signature Name Signature
_Phee May P. Diel ______________ ________________________ _____________
_ _ _
_______________________ ______________ ________________________ _____________
_ _ _ _
_______________________ ______________ ________________________ _____________
_ _ _ _
Endorsed by/ Recommended by _______Ana Helena Lovitos, Ph.D.______

Research Adviser/ Mentor
Date Filed: ________________________________________________

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UMERC– 004

Informed Consent Assessment Form Control No.: _______________

University of Mindanao Ethics Review Committee

IMPORTANT: All fields must be completed.

Research Title: Teacher Behavior and Student Attitude towards English

Date Submitted: September 11, 2019

Informed Consent Assessment Form Control No.: _______________

written consent form (e.g. illiterate patients) (Please explain on another

Name Signature Name Signature

_Phee May P. Diel __ _

Endorsed by/ Recommended by _Ana Helena Lovitos, Ph.D.

Date Filed: ________________________________________________

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