Katapatan Homes,

COLLEGE OFBrgy. Banay-banay,

HEALTH Cabuyao SCIENCES
& ALLIED City, Laguna

June 9, 2021

CONSENT FORM

Study Topic: THE EFFECTS OF EATING BREAKFAST IN MATH SKILLS

Description of Experiment: The experiment is expected to take about 20 minutes. It will be an online
interview using video conferencing application, Google Meet. The interview will be recorded a voice
recorder or screen recorder for purposes of accuracy in transcription. Rest assured that all information,
including pictures and videos that will be gathered in this study will be treated with confidentiality and
will be protected from unauthorized disclosures, tampering, or damage. Participation is voluntarily. You
have the right not to participate at all or to leave the experiment at any time. Deciding not to participate
or choosing to leave the experiment will not result in any penalty.

• I acknowledge that I have the right to opt out of the study at any time, and that any information
or details about me will be kept private.
• The study would be done in such a manner that I am not degraded in any way.
• At the result of the experiment, I will be debriefed and given the chance to learn the findings at
a later time.
• This experiment will be needed a material, paper, and pencil.

I hereby offer my informed consent to take part in this research:

Name: Jenny Claire J. Suyat

Age: 21 y/o

Signature:

Your participation will help the experimenters to complete their experiment, and it would be
greatly appreciated. Thank you!

Respectfully yours,

The Experimenters