INFORMED ASSENT FORM

Research Ethics Committee

Central Philippine University

ASSENT CONSENT FORM (ACF)

(VERSION No. 01-2021)

1. KEY INFORMATION ABOUT THE RESEARCHERS AND THEIR STUDY

Title of the Study: Knowledge, Beliefs, And Health Practices During Menstrual
Period Among Senior High School Students in a
Private University

Name of Researcher/s: Ma. Alexandria P. Pacificar

Marie Grace P. Padernal- Asst. Leader
Fayeh Harah A. Padrillan
Mary Antonette B. Pailon
Therese Marie B. Pallon- Leader
Kate Julia C. Palmares

Research Adviser: Dr. Charlie D. Baldon

Department/College: College of Nursing

Institution: Central Philippine University

2. INTRODUCTION

We are third-year students from the College of Nursing, who is/are currently conducting

a descriptive-correlational research on the Knowledge, Beliefs, and Health Practices during

Menstrual Period among Senior High School Students in a Private University. This

informed assent is given to ask for permission to be in part of the research study and will

provide you information that would influence your decision. The participant may speak or

consult anyone before making the decision. Your parental consent is required and the

respondents may speak or consult to anyone regarding the research before forming their

decision.
3. BACKGROUND AND PURPOSE OF THE STUDY

This study will be conducted to determine the respondent’s Level of Knowledge about

menstruation, Level of Beliefs towards menstruation, and Extent of Health Practices during

Menstrual Period among Senior High School Students in a Private University.

4. PROCEDURE OF THE STUDY

Sufficient time to read and comprehend the contents of the assent consent will be

provided before you decide to allow your child to participate in this study. Your questions will be

answered to your satisfaction. The study will begin once the assent consent form has been

signed. The content researcher-developed questionnaires will be delivered to the respondents

via google forms and will be asked to answer the questionnaire upon compliance of this consent

taking into consideration their schedule. The researchers will be available for any questions or

clarifications. After completion, it will be submitted to the researcher then the data will be

recorded accordingly. The above-mentioned procedure has been primarily made and intended

for the purpose of this study. All information gathering during this study will be private and

strictly confidential.

5. VOLUNTARINESS OF PARTICIPATION

Your participation/ your child’s participation in this study is entirely voluntary. It is your

choice whether to participate or not. If you choose not to participate or to withdraw from the

study at any time, there will be no penalty or other consequences and without need to give any

reason. If at any time you withdraw from the study, your data will be discarded properly.

6. RISKS AND INCONVENIENCES

During the conduct of the study, your child will be answering four parts of content

researcher-developed questionnaires that contain questions about your Demographic Profile,

Knowledge, Beliefs and Health Practices. There is a possibility that certain topics might come

out which may cause you anxiety, shame, and distress.

7. BENEFITS

This study may ask personal questions about senior high school students’ demographic

profile, knowledge, beliefs and health practices during their menstrual period. The researchers

will conduct the study with utmost confidentiality in order to protect the respondent’s identity and

respect the respondents’ decisions. This study could assist the senior high school students’ in

better understanding the importance of health education about menstruation to improve their

health outcomes. The respondents’ participation is completely voluntary and free of bias and

coercion. Respondents are also free to withdraw from the study at any time, but they must notify

the researchers in advance.

8. COSTS AND COMPENSATION

There is no amount that the participant needs to pay in joining this study.

There is also no compensation of any form that will be granted to the participant of this study.

9. PROVISION OF INJURY OR RELATED ILLNESS

During the conduct of the study, the researcher-developed questionnaires will be given

to the respondents via google forms. During the conduct of the study, Participants will be

answering four parts of content researcher-developed questionnaires that contain questions

about their Demographic Profile, Knowledge, Beliefs and Health Practices. There is a possibility

that certain topics might come out which may cause anxiety, shame, and distress to the

participants. If this occurs, the researcher will give assurance to the participants that all given

information will be kept private and strictly confidential.

10. PRIVACY AND CONFIDENTIALITY

 All the information gathered is solely for the purpose of this study. The identity of the

participants will be kept private and confidential to the extent provided by law. To maintain

anonymity as well as privacy, numbers rather than names of the respondents will be used. At

the conclusion of the study, recorded interviews, field notes, and documented narratives will be

kept by the researcher for safekeeping. The results of this study will be presented in a zoom

conference together with our research panel. These researcher materials will be disposed of

when the results of the study have been disseminated by the researcher.

11. WHO TO CONTACT

If you have any questions or clarifications regarding your participation in the study, you may

contact the researcher:

Principal Investigator: THERESE MARIE B. PALLON

Address: POBLACION, AJUY, ILOILO
Contact number: (63) 09985385221
E-mail: theresemarie.pallon-19@cpu.edu.ph

If you have questions pertaining to your rights as a participant, you may contact:

Chair, CPU Research Ethics Committee

Email: researchethcs@cpu.edu.ph
Phone: 329-1971 (local 3336)

12.CERTIFICATE OF ASSENT

I understand that I am being asked to permit my child to participate in a research study

entitled Knowledge, Beliefs, and Health Practices during Menstrual Period among Senior High

School Students in a University. This study aims to determine the Knowledge, Beliefs, and

Health Practices during Menstruation among Senior High School Students in a Private

University. If I agree to participate in this study, I will be able to give my experiences on what is

being asked in the questionnaire. I realize that the knowledge gained from this study may

benefit my child or the organization to which the study is related. I understand that my

participation in the study is voluntary, and that I may withdraw at any moment. If I choose to
withdraw my participation, I will be handled in a casual and customary manner. I understand

that all research data will be kept confidential. Information, on the other hand, may be used in

publications or presentations. This study has been explained to me. I have read and understand

this consent form, have had all of my questions answered, and I agree to participate.

I understand that I will be given a copy of this signed Assent form.

I have read this information (or had the information read to me) . I have had my questions

answered and know that I can ask questions later if I have them.

I agree to permit my child to take part in the research.

Print name of parent: ___________________

Signature of parent: ____________________

Date: [DD/MM/YYYY]

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.

Print name of witness (not a parent) ________________

Signature of witness ______________________

Date: [DD/MM/YYYY]

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: [DD/MM/YYYY]