INFORMED CONSENT FORM

TITLE
Health Sanitation and Skin Conditions Among Residents in Sitio Malaking Irigasyon,
Barangay Talipan, Pagbilao Quezon: Basis for Household Sanitation Program

STUDY PROPONENT/ PRINCIPAL INVESTIGATOR

Camille Guinto
Lead Researcher

INTRODUCTION
You are being invited to participate in this study because you qualify as one of the subjects
that could help in the advancement of this research. You fit in the category of subject:
 Resident of Sitio Malaking Irigasyon
 Has a family member/s that manifests/suffers from a skin condition.

This consent form provides you with information to help you make an informed choice.
Please read this document carefully. If you have any questions, they should be answered to
your satisfaction before you decide whether to participate in this research study.

PURPOSE OF THE STUDY

The objective of the study is to:
 To determine the health sanitation practices among the residents
 To determine various skin conditions among the residents
 To determine the relationship of health sanitation practices to the skin conditions
presented by the family member/s.
 To establish as household sanitation program

STUDY DESIGN AND PARTICIPANTS ROLE

The study utilized the descriptive-correlational survey method of research with adopted
questionnaire checklist as an instrument to answer the research problems. This method
was employed since the general aim of the study is to determine the household sanitation
practices in the community, and correlate this to the present skin conditions. The subject’s
role is to answer the questionnaire given by the researcher by putting a check on the option
that best stated their opinion. The participant will also allow the researcher to carry out
observations inside their household.

TERMS OF PARTICIPATION

BENEFITS
Skin conditions present in the family will be evaluated by the researcher and the Health
Sanition Program will be carried out in the participant’s household. This includes health
teaching on the care management of skin conditions, how to maintain effective household
sanitation and hygiene, and how to reduce the likelihood of developing different skin
conditions.
PRIVACY AND CONFIDENTIALITY
Personal Identifiers of the participants will not be revealed at any part of the study
including reporting and dissemination. Data provided by the subjects will be used solely for
the purpose of the research

CONTACT INFO
If you have further questions or concerns about your participation in this study, or if you
suffer any injury related to the study, please contact:

CAMILLE GUINTO
Lead Researcher
Camilleguinto25@gmail.com
Mobile: 09811627448

Conforme:
 I understand that taking part is voluntary; I can withdraw from the study at any
time and I do not have to give and reasons for why I no longer want to take part
 All of my questions and concerns have been answered
 I understand the information indicated in this informed consent form.
 I understand that my participation in this study includes going to the check up as
scheduled
 By signing this form, none of my legal rights have been given up

__________________________________________________ _________________
Signature Over Printed Name of Subject Date