Republic of the Philippines

DAVAO ORIENTAL STATE COLLEGE OF SCIENCE AND TECHNOLOGY

Guang-guang, Dahican, City of Mati

CONSENT AGREEMENT FORM

Interviewer: _
Course:
School: _ _ _

Description of the Interview:

This CHILD PROFILING aims to study child’s developmental milestone as

he/she interacts to his/her environment. Developmental milestone could influence
the learning process of the students, this study will help the teacher to facilitate on
how to maximize the potential of the child.
Your participation will be very helpful in providing information about your child
developmental history in relation to his/her developmental milestone. I’m interested
in hearing about your experiences in rearing and raising your child either at home or
in school. I will ask you series of questions of open-ended interview questions. The
entire interview should take about twenty to thirty minutes.
Thank you very much for participating in an interview. Your participation is
completely voluntary. You can choose not to participate at any time or change your
mind, and you can stop answering questions at any time.

Risk and Benefits

Some of my questions may be personal and may focus on your feelings about
your experiences with the program as well as other personal experiences. There is a
risk that you may experience feelings of anxiety, anger, or sadness as you answer
some of the questions. I encourage you to seek counseling if this interview brings out
issues that you would like to someone about and therefore, you will be provided with
a list of counseling resources. You may request a break at any time or refuse to
answer the question at any time.

Confidentiality

All of the information that you share is confidential. I will never include your
name or any of your identification information with the information that I receive from
you. I will keep notes and recordings from our entire interview on a secure laptop
with privacy control settings to ensure confidentiality. All identifying material,
including this signed consent form, will be stored separately in a locked filed cabinet.
Other than myself, my advisor, who is overseeing my project, will have access to
these records.
If you do not wish to be tape recorded, I will take handwritten notes that will
not be shown to anyone else. Records will be kept confidential to the extent provided
by the republic of the Philippines or local law. However, the DOSCST Faculty
Advisor is responsible for monitoring this study and may inspect the records. One
copy of this document will be kept together with the records of this study. Also, you
will be given a copy to keep.

Contact information

If you have questions or comments about this study, you may contact the
researcher, __ at any time. His handphone number is
. You may contact also my advisor in DOSCST-Main Campus
at Guang-guang, Dahican, City of Mati with. His handphone number is
09075223719.

CONSENT TO PARTICIPATE IN THIS INTERVIEW:

I have read [or been informed] of the information given.

has offered to answer questions I may have
concerning the study. I hereby consent to participate in the study.

Name and Signature Date

CONSENT TO BE TAPE-RECORDED/HANDWRITTEN NOTES:

Please put a check mark on the box provided before the statement.
□ I am willing to have this interview tape-recorded.
□ I am willing to have the interview recorded in handwritten notes.

Name and Signature Date

CONSENT TO BE TAKEN PHOTO SHOTS:

Please put a check mark on the box provided before the statement.
□ I am willing to have this interview documented through photo shots.
□ I am willing to have the interview documented but photo shots are
silhouette or the back portion only.

Name and Signature Date

 Republic of the Philippines
DAVAO ORIENTAL STATE COLLEGE OF SCIENCE AND TECHNOLOGY
Guang-guang, Dahican, City of Mati

April 28, 2020

_
___

Sir/Madame:

Greetings of peace and solidarity!

As part of our instructional aspiration is to expose our students through several

academic endeavor in order for them to experience at the same time witness the real
scenario of the different events discussed inside the classroom. Indeed, learning
doesn’t only found within the corners of the classroom.
I would like to let my students to have an actual engagement and observation with
regards to developmental milestone of an individual as part of the requirement of
their subject.

With this regard, I would like to knock your generous heart to allow my students to
conduct their observation and interview. I and my students are willing to abide with
your standards regarding this interview. On the other note, this profile would be of
great help to the part of the teachers in order for them to be enlightened with the
future result.

Rest assured that we will establish strict compliance of confidentiality about the
result. I would like to emphasize that you can give a short orientation with my
students about your policies and guidelines if possible. I am open to have a short talk
with you at your convenient time. You can reach me by this mobile number
09075223719.
This will open an opportunity for the students for new learning. Your approval about
this activity is highly appreciated. May this letter be worthy for your consideration.

God bless!

Sincerely yours,

ROBIE V. CATUBIGAN
Instructor