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    Form 2.4 Informed Consent Evaluation Form 1 2024 versionNEW VERSION

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    anoymousderron

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    Form 2.4 Informed Consent Evaluation Form 1 2024 versionNEW VERSION

    Uploaded by

    anoymousderron
    1 views3 pages

    Original Title

    Form-2.4-Informed-Consent-Evaluation-Form-1-2024-versionNEW-VERSION

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    Copyright:

    © All Rights Reserved
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    Download as docx, pdf, or txt
    1 views3 pages

    Form 2.4 Informed Consent Evaluation Form 1 2024 versionNEW VERSION

    Uploaded by

    anoymousderron

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    University of Cebu

    Academe
    Research Ethics Committee
    Informed Consent Evaluation Form
    Form 2.4

    Part 1. to be filled by the PI


    PROTOCOL TITLE:
    CANTEEN SERVICES
    SATISFACTION SURVEY
    PROTOCOL NO. : Type of Review:
    PRINCIPAL INVESTIGATOR: CONTACT DETAILS: (email add & mobile number)
    D/C PRACULLOS,DERRON P. anoymousderron@gmail.com/ 09165643149
    ADVISER: CONTACT DETAILS: (email add & mobile number)
    CARLY MAE SUICO, LPT MAED cmsuico@uc.edu.ph/09958439157
    INSTITUTION: Status:
    UNIVERSITY OF CEBU - METC ✘ NEW Re-submission

    REVIEWER:

    Part 2. to be filled by the ICF Reviewer


    GUIDE FOR REVIEWING THE INFORM CONSENT PROCESS & FORM
    1. Is it necessary to seek the Informed Consent of the participants?

    Unable to Assess YES NO

    IF NO, please explain

    IF YES, are the participants provided with sufficient information about the following
    items?

    YES NO N/A
    o Purpose of the study?

    o Statement describing the purpose of the study


    o Study-related treatments and probability for random
    assignment
    o Study procedures including all invasive procedures

    o Responsibilities of the participant

    o Approximate number of participants in the study


    2

    o Study aspects that are experimental


    o Foreseeable risks to participant/embryo/ fetus/nursing
    infant; including pain, discomfort, or inconvenience
    associated with participation including risks to spouse
    or partner;
    o Risks (including possible discrimination)?
    o Reasonably expected benefits; or absence of direct
    benefit to participants, as applicable
    o Expected benefits to the community or to society, or
    contributions to scientific knowledge
    o Expected duration of participation in the study
    o Description of post-study access to the study product
    or intervention that have been proven safe and
    effective
    o Alternative procedures or treatment available to
    participant
    o Compensation or insurance or treatment entitlements
    of the participant in case of study-related injury
    o Anticipated payment, if any, to the participant in the
    course of the study; whether money or other forms of
    material goods, and if so, the kind and amount
    o Compensation (or no plans of compensation) for the
    participant or the participant’s family or dependents in
    case of disability or death resulting from study-
    related injuries
    o Discomforts and inconvenience?
    o Who to contact for pertinent questions and/or for
    assistance in research-related concerns or injury?
    o Extent of
    confidentiality?
    2. Is the inform consent written or presented in non-technical language that participants can
    understand?

    Unable to Assess YES NO

    3. Does the protocol include an adequate process for ensuring that the consent is voluntary?

    Unable to Assess YES NO

    4. Are the different types of consent forms (assent, patient representative) appropriate for the types
    of study participants?

    Unable to Assess YES NO

    Review Ethics Committee | Form 2.4 | Informed Consent Evaluation Form 1-2024
    3

    5. Are the names and contact numbers from the research team and REC in the informed consent?

    Unable to Assess YES NO

    6. Is the Informed Consent translated into the local language/dialect? (if applicable)

    Unable to Assess YES NO

    7. Do you have any other concerns?

    RECOMMENDATION:
    APPROVED
    Minor Revisions Required
    Click or tap here to enter text.
    Major Revisions Required
    Click or tap here to enter text.
    DISAPPROVED
    Reasons for disapproval: Click or tap here to enter text.

    Signature over Printed Name Date Reviewed

    Review Ethics Committee | Form 2.4 | Informed Consent Evaluation Form 1-2024

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