INFORMED CONSENT FORM

Title of the Study: Lived Experience of Mothers of Children with Speech

Delays in Surigao City, Surigao del Norte Philippines:
Challenges, Coping Mechanisms, and Possible
Interventions

Researcher: Chonamie Ramos

Master of Arts in Education Major in Special
Education

INTRODUCTION
This study aims to determine the lived experiences of the mothers with children who
has speech delays in Surigao City, Surigao del Norte, Philippines. This will further
determine the challenges they have encountered in rearing the children. With this,
the participants of this study will allow not just the researcher but also the personnel
involved in gaining data, analyzing them, and crafting possible interventions that will
help the participants of this study.

Hence, to further the cause of bettering the understanding of the people in society
and allow for the stakeholders of local officials, education department, and the social
welfare department to craft and implement necessary measures to ensure premium
benefits and help to the mothers experiencing challenges, you are invited to
participate in this research study.

PROCEDURE OF DATA GATHERING

If you will participate, the researcher, Chonamie Ramos, will have a two-part stage
for you to respond. Stage 1 will include the simple answering of survey questionnaire
regarding on the socio-demographic profile of the respondents and Stage 2 will be a
focus group discussion regarding on the lived experiences, challenges, and methods
of coping.

The Stage 1 shall happen in thru google forms which you are asked to answer some
basic information. For the conduct of Stage 2, you will be informed ahead of time
regarding on the flow of the focus group discussion. The focus group discussion will
happen via online, you will be using only your nickname or code name during the
online session, and all your personal data will be kept confidential in line with the
Data Privacy Act of 2012.

In case you feel uncomfortable answering questions in the survey and in the focus
group discussion, you have the right not to respond during the process.

RISKS
There are no possible risks for the participation of this study

BENEFITS
If you decided to participate, a 100 Php load will be given to each of the participants.
The information obtained from this study will be the baseline for the stakeholders to
craft interventions or program that will address the challenges experienced by the
mothers. The researcher will be shouldering the expenses necessary in the conduct
of the study.

COST AND COMPENSATION

The participants will not have any costs related to the participation of this study other
that the time to spend in the survey questionnaire and in the focus group discussion.

CONFIDENTIALITY
Recordings, personal information, and other participant-related information will be
kept confidential before, during, and after the conduct of the study as mandated by
the laws of the land unless superseded by the court. However, the Research Ethics
Committee of the University of Southeastern Philippines Foundation may scrutinize
the quality assurance and data analysis record for the validation of the results of this
study.

In response to the confidentiality statements, the following protocols shall be

implemented in the data gathering procedure:

1. The researcher shall inform the participants the necessary information and
preparation before conducting the data gathering.
2. The focus group discussion shall be recorded and transcribed thereafter for
data gathering and analysis of the study.
3. The raw data and information obtained from the participants shall be kept
confidential. The completion and publication of this study will not allow the
identity and personal information be published publicly.

PARTICIPANT QUESTIONS
If ever you have questions regarding on this study and the terms provided in this
informed consent, you can contact me thru the following platform

Facebook Namie Ramos

Gmail chonamie2019@gmail.com
Cellphone 09275283253
Number

PARTICIPANT INVOLVEMENT
Upon affixing your signature below, you voluntarily agree to participate in the
conduct of this study and that the study’s aim and protocols have been explained to
you, that you have been given time to reed this document, and that your questions
have been satisfactorily answered. You will receive a copy of the written informed
consent before the participation of the study.
 SLIP OF VOLUNTARY PARTICIPATION

As I affix my signature over my printed name, I voluntarily agree to participate in this

study, have known the aims and protocols to be employed during the data gathering,
have made clear any questions from the researched.

Thus, I can be contacted thru the following platforms:

Facebook _____________________________
Gmail _____________________________
Cellphone Number _____________________________
Other Contact Info _____________________________

signifying my participation, thus

_____________________________ _____________________________
Signature over Printed Name Date
 SURVEY QUESTIONNAIRRE

Directions: Please read and fill out the survey questionnaire that reflects the truth in
your part. If you have questions regarding on any of the item, please do not hesitate
to ask questions form the researcher.

Name (Optional): _____________________________________ Age: _____

Marital Status: _____ Single Highest _____ Elementary

_____ Married Educational _____ Elementary Graduate
_____ Annulled Attainment: _____ High School
_____ Widowed _____ High School Graduate
_____ Others, please _____ College
specify ____________ _____ College Graduate
_____ Masters
_____ Masters Graduate
_____ Doctorate
_____Doctorate Graduate
_____ Post Doc
_____ Technical Vocational
_____ Others, please
specify___________

Monthly Income: _____ Lower than 10,000 Number _____

in Pesos _____ 10,000 – 20,000 of
_____ 21,000 – 30,000 Children:
_____ 31,000 – 40,000
_____ 41,000 – 50,000
_____ 51,000 higher
_____ Others, please
specify _____________
 INTERVIEW QUESTIONNAIRRE

1. What are your rearing methods of your child?

a. Have you hired a nanny to rear your child?

b. How did you or your nanny rear your child, according to

b.1. Speaking,

b.2. Eating,

b.3. Walking or any physical activities.

2. What is the diagnosis of your child regarding on the speech difficulty?

a. What was your first reaction after knowing the diagnosis?

b. How did you accept the diagnosis of your child?

3. Is there anything you would like to share about your experiences with your

child while rearing him until he learned to speak well?

a. What adjustments did you do

a.1. Physical aspects;

a.2. Emotional aspects;

a.3. Financial aspects;

a.4. Psychological aspects; and

a.5 Social aspects

b. What are the different experiences you learned from these aspects,

b.1. Physical aspects;

b.2. Emotional aspects;

b.3. Financial aspects;

b.4. Psychological aspects; and

b.5 Social aspects

4. What are the different challenges you faced while dealing with your

experience in handling your child in the

a. Physical aspects;

b. Emotional aspects;

c. Financial aspects;

d. Psychological aspects; and

e. Social aspects

5. How did you cope or overcome these challenges, as to

a. Physical aspects;

b. Emotional aspects;

c. Financial aspects;

d. Psychological aspects; and

e. Social aspects

6. How did you clinically/medically address the diagnosis of your child?

a. Is it personal? or

b. Assistance from the government or NGO?

7. What support or assistance did you receive from the government or NGO, as

to

a. Medical; and

b. Psychosocial?

8. How does this assistance help you?

9. Are the assistances from the government or NGO good?

a. Why? Or

b. Why not?