CONFIDENTIALITY AGREEMENT

Title: Medical Student Syndrome phenomenon among First-Year to Third-Year Medical

Students in University of St. La Salle
The following agreement is entered into this _________ day of ________, 20________, between
the USLS medical student researchers and ________________________________ (participant).
Purpose: The purpose of this agreement is to document the confidentiality provided to the
participant and researchers. The limits of this confidentiality to assure protection of mental
health, safety and welfare of both parties.
Confidentiality: You will be assigned with a number or code to assure anonymity within the
study.
Consent: In order to administer the study effectively, the researchers need your consent as
evidenced by your full signature for disclosure under certain circumstances. With your consent,
the researchers will have full understanding about their responsibilities and accountabilities and
agreed to the following:
1. The researchers must keep all the research information confidential.
2. The researchers will not discuss or share any research information, recordings, consent
forms, interview tapes or notes with anyone other than their fellow researcher(s) or panel
evaluators.
3. The researchers must keep all information secured in a safe place while it is in their
control.
4. The researchers must not read information of participants nor ask questions for their own
personal intention but only to the extent and purpose of performing their assigned duties
on this study.
5. The researchers must destroy all information about the participants after publication of
the study.
Agreement: Upon understanding the liabilities of the researchers on the study that I am involved
with; I hereby agree to the following:
1. I understand that the researchers may access personal or sensitive information regarding
with the study and must be kept with utmost confidentiality
2. I understand that I shall not reveal or publish any information about the researchers or
participants in this study.
3. I understand that any information about the investigation area and study itself are
extremely confidential.
4. I acknowledge that any violation of the terms and conditions may result in termination of
my participation in this research study.
5. I agree to be completely bound by the terms of this agreement.

Name of participant: _________________________________________________________

Signature: _________________________________________________________________
Date: _____________________________________________________________________