Parental Consent Form

This Informed Consent form is for the parent or legal guardian of male and
female second year student in selected universities in Caloocan and Valenzuela City,
and who I am inviting their children to participate in a research study entitled
Predictors of Intent of College Students to Hepatitis B Vaccination in Selected
Universities

Part I: Information Sheet

Introduction
I am Mr. Christopher Ponce T. Nuqui, studying my Master Degree in Nursing
in Our Lady of Fatima University Graduate School, Valenzuela City. I am doing a
research entitled Predictors of Intent of College Students to Hepatitis B Vaccination
in Selected Universities to check the compliance of the allied medical students
compliance to Hepatitis B vaccination.
Your child is invited to be in a research study regarding their perception to
Hepatitis B vaccine and their compliance. Your child was selected as a possible
participant because your child is in the age range we are interested in studying. We
ask that you read this form and ask any questions you may have before agreeing to
have your child in this study.

I am going to give you and your child information and invite him/her to be
part of this research. You do not have to decide today whether or not you will allow
your child to participate. Before you decide, you can talk to anyone you feel

comfortable with about my study. This consent form may contain words that you may
not understand, please do not hesitate to ask me to stop as I go through the
information and I will take time to explain it more clearly. If you have questions later,
you can approach me.

Purpose of the Research

The researcher would like to study or identify the predictors of Intent of
College students in selected educational institutions to receive the Hepatitis B
vaccination using the health belief model as a framework. Moreover, these predictors
of intent pertain to the perception of your son/daughter to Hepatitis B vaccination and
Hepatitis B virus which may influence their compliance to complete their vaccination.
The information that will be elicited from this study will serve as a basis for
appropriate interventions which is not limited to policy development in schools that
offer allied health courses and increase information drive in the community.

Type of Research Instruments

This research study will involve your childs participation by answering two (2)
parts of the data gathering instruments namely: 1) respondents profile form; 2)
Predictors of intent which consists of the perceived severity of Hepatitis B Infection,
perceived susceptibility to Hepatitis B virus, perceived barriers and perceived benefits
to Hepatitis B vaccine.
Participant Selection
All male and female 2nd year students of Dentistry, Nursing and Medical
Technology program enrolled in an Educational Health Institution in Caloocan and

Valenzuela City. They are invited to participate in this research on Predictors of Intent
of College Students to Hepatitis B Vaccination in Selected Universities.

Voluntary Participation
Your child is being invited to take part in this study and his/her participation is
entirely voluntary and according to your free-will. It is your choice whether to let your
son/daughter participate or not. The choice that you will make will have no bearing to
any aspects to the relationship of the University in which your child is currently
studying. You and your child may change your mind later and withdraw your
participation even if you agreed earlier.

Procedures, Protocol, and Description of the Process

Initially, the researcher will conduct an orientation for you & your child with
regards to the research study wherein the study procedures will be discussed
thoroughly, the duration of the study, as well as the risks and benefits of the study.
Afterwards, questions will be entertained by the researcher in connection with the
study for the purpose of clarification. Thereafter, you and your child will be asked to
accomplish and sign the consent form if you are willing to participate in the study in
the absence of coercion or threat. If you will voluntarily sign the consent and
participate in the study, your son/daughter will be asked to accomplish the two (2)
research instruments namely: 1) respondents profile form; 2) predictors of intent
which comprises the perceived severity and

perceived susceptibility to hepatitis B

virus; and perceived barriers and perceived benefits to Hepatitis B Vaccine .

Accomplishing these instruments will require 30-60 minutes of your time and another
30 minutes for clarification and validation of your answers.

Duration
This research study will take place from July 1-30, 2016 and will involve your
childs participation by answering two (2) data gathering instruments namely: 1)
respondents profile form; 2) predictors of intent which comprises the perceived severity
and perceived susceptibility to hepatitis B virus; and perceived barriers and perceived
benefits to Hepatitis B Vaccine. Accomplishing these instruments will require 30-60
minutes of your time and another 30 minutes for clarification and validation of your
answers.

Risks
The research instruments will be asking your child to share some confidential
information, and if he/she may feel uncomfortable talking about some of the topics.
He/she does not have to answer any questions in the instrument if she/he doesnt
wish to do so, and that is also fine. He/she does not have to give any reason for not
responding to any question. If ever you and your child have any queries, please feel
free to open up and the researcher will be very much eager to accommodate your
concerns.

Benefits
The result of this study could be forwarded to the administrators of your childs
university; thus, this may help in improving the protocol regarding Vaccination among
students who are at risk to be infected. In addition, this could improve you and your
childs self-awareness regarding the compliance to Hepatitis B vaccination.

Reimbursements

You and your child will not be provided any incentive for taking part in this
research. However, I will give him/her a token of appreciation as my expression of
gratefulness for being participative in the entire duration of the study.

Confidentiality
All information that your child will provide for this research study will be kept
confidential and will be used only for the conduct of the research. All information will
stay put on the researcher and no other people will have an access on it except Dr.
Fred Ruiz as the researchers adviser, and unless it will required for publication. In
case publication will be required, it will be brought to your knowledge and awareness
and your approval for publication will be sought. All your childs information will have
a number instead of his/her name and only the researcher will know what her number
is and it will be locked with a lock and key.

Sharing the Results

Results of the study will be explained to you and your child and a copy of the
study may be given to you and him/her in case you request for it. Thus, in case
publication will be required, it will be brought to your knowledge and awareness and
your approval for publication will be sought. However, confidential information will not
be shared.

Right to Refuse
You or your child do not have to participate in this research if you do not feel
comfortable to do so and refusing to participate will not affect any aspect of your
personal and professional life. You will still enjoy and have the benefits and privileges

that you have despite of not participating in this study. Your daughter/son may also
withdraw his participation in this research study in any phase or any time that he/she
feel like uncomfortable without losing any of his benefits and privileges.

Who to Contact
If you have any questions, you can ask me now or feel free to contact me at
09174581908 or e-mail me at christophernuqui85@gmail.com and rest assured that
all your concerns will be addressed the best way I can.
This proposal has been reviewed and approved by Our Lady of Fatima University
Research Ethics Review Committee, which is a committee whose task is to make sure
that research participants are protected from harm. If you wish to find more about
OLFU Research ERC, you may contact __________________________________________.

Part II: Certificate of Consent

I have been invited to participate in the research on Workplace Bullying and

Coping Strategies among Nurses. Likewise, I have read and understand the foregoing
information thus; it was read and explained to me by Mr. Christopher Ponce T. Nuqui
to the level of my understanding. I had the opportunity to ask him questions about his
study and all questions I had asked has been answered to my satisfaction. Therefore, I
consent voluntarily to be a participant in this study.

Printed Name and Signature of the Parent/

Legal guardian:_____________________________________________________

Printed Name and Signature of Witness: _____________________________

Date: _________________________________

If Illiterate
I have witnessed the accurate reading of the consent form to the potential
participant, and the individual has had the opportunity to ask questions. I confirm
that the individual has given consent freely.

Printed Name and Signature of Witness: _____________________________

Date: _________________________________

Thumb Print of Parent or Legal guardian:

Statement by the Researcher / Person Taking Consent

I have accurately read out the information sheet to the potential respondent, and to
the best of my ability made sure that the respondent understands that the following
will be done:
1. Orientation about the research process
2. Informed Consent signing
3. Answering of two (2) data gathering instruments namely: 1) respondents profile
form; 2) predictors of intent which comprises the perceived severity and perceived
susceptibility to hepatitis B virus; and perceived barriers and perceived benefits to
Hepatitis B Vaccine.

I confirm that the respondent was given an opportunity to ask questions about the
study, and all questions asked by the respondent have been answered correctly and to
the best of my ability. I confirm that the individual has not been coerced into giving
consent, and the consent has been given freely and voluntarily. Thus, a copy of this
informed consent form has been provided to the respondent.

Printed Name of the Researcher / Person Taking the Consent:

_________________________________________________________

Signature of the Researcher / Person Taking the Consent:

_________________________________________________________

Date: __________________________________

Assent Form

This Informed Consent form is for male and female second year student in
selected universities in Caloocan and Valenzuela City, and who I am inviting to
participate in a research study entitled Predictors of Intent of College Students to
Hepatitis B Vaccination in Selected Universities

Part I: Information Sheet

Introduction
I am Mr. Christopher Ponce T. Nuqui, studying my Master Degree in Nursing
in Our Lady of Fatima University Graduate School, Valenzuela City. I am doing a
research entitled Predictors of Intent of College Students to Hepatitis B Vaccination
in Selected Universities to check the compliance of the allied medical students
compliance to Hepatitis B vaccination.
I am going to give you information and invite you to be part of this research.
You do not have to decide today whether or not you will participate. Before you decide,
you can talk to anyone you feel comfortable with about my study. This consent form
may contain words that you may not understand, please do not hesitate to ask me to
stop as I go through the information and I will take time to explain it more clearly. If
you have questions later, you can approach me. Furthermore, if you are below 18 years
old, I would like to request your parent or legal guardians approval.

Purpose of the Research

The researcher would like to study or identify the predictors of Intent of
College students in selected educational institutions to receive the Hepatitis B
vaccination using the health belief model as a framework. Moreover, these predictors

of intent pertain to the perception of the students to Hepatitis B vaccination and

Hepatitis B virus which may influence their compliance to complete their vaccination.
The information that will be elicited from this study will serve as a basis for
appropriate interventions which is not limited to policy development in schools that
offer allied health courses and increase information drive in the community.

Type of Research Instruments

This research study will involve your participation by answering two (2) parts of
the data gathering instruments namely: 1) respondents profile form; 2) Predictors of
intent which consists of the perceived severity of Hepatitis B Infection, perceived
susceptibility to Hepatitis B virus, perceived barriers and perceived benefits to
Hepatitis B vaccine.

Participant Selection
All male and female 2nd year students of Dentistry, Nursing and Medical
Technology program enrolled in an Educational Health Institution in Caloocan and
Valenzuela City. They are invited to participate in this research on Predictors of Intent
of College Students to Hepatitis B Vaccination in Selected Universities.

Voluntary Participation
You are being invited to take part in this study and your participation is entirely
voluntary and according to your free-will. It is your choice whether to participate or
not. The choice that you will make will have no bearing to any aspects of your personal

and professional life. You may change your mind later and withdraw your participation
even if you agreed earlier.

Procedures, Protocol, and Description of the Process

Initially, the researcher will conduct an orientation for you with regards to the
research study wherein the study procedures will be discussed thoroughly, the
duration of the study, as well as the risks and benefits of the study. Afterwards,
questions will be entertained by the researcher in connection with the study for the
purpose of clarification. Thereafter, you will be asked to accomplish and sign the
consent form if you are willing to participate in the study in the absence of coercion or
threat. If you will voluntarily sign the consent and participate in the study, you will be
asked to accomplish the two (2) research instruments namely: 1) respondents profile
form; 2) predictors of intent which comprises the perceived severity and

perceived

susceptibility to hepatitis B virus; and perceived barriers and perceived benefits to

Hepatitis B Vaccine . Accomplishing these instruments will require 30-60 minutes of
your time and another 30 minutes for clarification and validation of your answers.

Duration
This research study will take place from July 1-30, 2016 and will involve your
participation by answering two (2) data gathering instruments namely: 1) respondents
profile form; 2) predictors of intent which comprises the perceived severity and
perceived susceptibility to hepatitis B virus; and perceived barriers and perceived
benefits to Hepatitis B Vaccine. Accomplishing these instruments will require 30-60
minutes of your time and another 30 minutes for clarification and validation of your
answers.

Risks
The research instruments will be asking you to share some confidential
information, and you may feel uncomfortable talking about some of the topics. You do
not have to answer any questions in the instrument if you dont wish to do so, and
that is also fine. You do not have to give any reason for not responding to any question.
If ever you have any queries, please feel free to open up and the researcher will be very
much eager to accommodate your concerns.

Benefits
The result of this study could be forwarded to the administrators of your
university; thus, this may help in improving the protocol regarding Vaccination among
students who are at risk to be infected. In addition, this could improve your selfawareness regarding the compliance to Hepatitis B vaccination.

Reimbursements
You will not be provided any incentive for taking part in this research. However,
I will give you a token of appreciation as my expression of gratefulness for being
participative in the entire duration of the study.

Confidentiality
All information that you will provide for this research study will be kept
confidential and will be used only for the conduct of the research. All information will
stay put on the researcher and no other people will have an access on it except Dr.
Fred Ruiz as the researchers adviser, and unless it will required for publication. In

case publication will be required, it will be brought to your knowledge and awareness
and your approval for publication will be sought. All your information will have a
number instead of your name and only the researcher will know what your number is
and it will be locked with a lock and key.

Sharing the Results

Results of the study will be explained to you and a copy of the study may be
given to you in case you request for it. Thus, in case publication will be required, it will
be brought to your knowledge and awareness and your approval for publication will be
sought. However, confidential information will not be shared.

Right to Refuse
You do not have to participate in this research if you do not feel comfortable to
do so and refusing to participate will not affect any aspect of your personal and
professional life. You will still enjoy and have the benefits and privileges that you have
despite of not participating in this study. You may also withdraw your participation in
this research study in any phase or any time that you feel like uncomfortable without
losing any of your benefits and privileges.

Who to Contact
If you have any questions, you can ask me now or feel free to contact me at
09174581908 or e-mail me at christophernuqui85@gmail.com and rest assured that
all your concerns will be addressed the best way I can.

This proposal has been reviewed and approved by Our Lady of Fatima University
Research Ethics Review Committee, which is a committee whose task is to make sure
that research participants are protected from harm. If you wish to find more about
OLFU Research ERC, you may contact __________________________________________.

Part II: Certificate of Consent

I have been invited to participate in the research on Workplace Bullying and

Coping Strategies among Nurses. Likewise, I have read and understand the foregoing
information thus; it was read and explained to me by Mr. Christopher Ponce T. Nuqui
to the level of my understanding. I had the opportunity to ask him questions about his
study and all questions I had asked has been answered to my satisfaction. Therefore, I
consent voluntarily to be a participant in this study.

Printed Name and Signature of Participant: __________________________

Printed Name and Signature of Witness: _____________________________

Date: _________________________________

If Illiterate

I have witnessed the accurate reading of the consent form to the potential
participant, and the individual has had the opportunity to ask questions. I confirm
that the individual has given consent freely.

Printed Name and Signature of Witness: _____________________________

Date: _________________________________

Thumb Print of the Participant:

Statement by the Researcher / Person Taking Consent

I have accurately read out the information sheet to the potential respondent, and to
the best of my ability made sure that the respondent understands that the following
will be done:
4. Orientation about the research process
5. Informed Consent signing

6. Answering of two (2) data gathering instruments namely: 1) respondents profile

form; 2) predictors of intent which comprises the perceived severity and perceived
susceptibility to hepatitis B virus; and perceived barriers and perceived benefits to
Hepatitis B Vaccine.

I confirm that the respondent was given an opportunity to ask questions about the
study, and all questions asked by the respondent have been answered correctly and to
the best of my ability. I confirm that the individual has not been coerced into giving
consent, and the consent has been given freely and voluntarily. Thus, a copy of this
informed consent form has been provided to the respondent.

Printed Name of the Researcher / Person Taking the Consent:

_________________________________________________________

Signature of the Researcher / Person Taking the Consent:

_________________________________________________________

Date: __________________________________