INFORMED CONSENT FORM

Action research title: Diet and ABO Antibody Titer Reasearchers: Valdez, Dennis Bryan A. Bangay, Marc Joseph Pasion, Jared Kenan S. Repoyo, Berlanne A. Mendoza, Alliana Jean D. Paltep, Rashell Anne C. Opina, Ann P. Phone: (09205702396) Email: annpopina@yahoo.com.ph Saint Louise University Greetings! You are being invited to participate in the study entitled Diet and ABO Titer under the supervision of Miss Anne Opia. The information provided on this form and the accompanying cover letter is presented to you in order to fulfill the legal and ethical requirements for research studies at the Saint Louis University, Baguio City. Note that the following must have been explained well to you and you fully understand them before you sign this consent form. 1. The purpose of this study is to assess the effect of diet on the ABO antibody titer of the respondents. The knowledge gained from this study will guide the patients and also other healthcare professionals about the implications of the kind of diet they are taking in their antibody titer before blood transfusions. 2. Participation is voluntary. Refusal to participate or withdrawal from the study will present no penalty to participant. 3. The number of study participants is all BMLS third year students in Saint Louis University. 4. The duration of the study will be two semester ( June 2013- March 2014). 5. According to the researchers, reactions prior to blood extraction may include fear and uncontrolled behavior; during the collection, pain and bleeding may occur. If it happens, the researchers will not proceed immediately with the extraction or may stop the extraction process and give further instructions for you to follow.

6. In case of adverse reactions, there will be immediate treatment/hospitalization which will be available free charge. The researchers will provide reimbursement or payment for the treatment and other expenses incurred because of the adverse event. 7. All your records or information will be kept strictly confidential. 8. You will be given information or results of the results of the tests that may be relevant to your continued participation. You will also be informed of any new information which may be relevant to your continued participation. 9. You can call or ask questions anytime regarding this study. The contact person for further information or for consultation on diverse events is attached herewith. 10. Your signature on this consent form shows that you have been informed about the conditions and safeguards of this prject. Ann P. Opia I have read the information provided and I agree to participate in this study

_________________________________ Signature of Participant, Date