ATENEO SCHOOL OF MEDICINE AND PUBLIC HEALTH

INFORMED CONSENT (ADULT)

Title of Research: A matched case-control study on the association between depression
and the extent of delay in the diagnosis and treatment of pulmonary tuberculosis among
patients in TB DOTS Clinics in Quezon City, Pasig City and Marikina City.
Name of Principal Investigators and Contact Details:
1. Barlisan, Adel Karlo: +639175688064
2. Bueno, Pauline Lourdes
3. Laurel, Juan Miguel Jr.
4. Mangaoang, Czarina Dianne: +639178196117
5. Parungo, Manuel Karlo: +639178153140
6. Rafael, Jeffrey Celso Mari
7. Ruby, Maria Franchina

A. PURPOSE AND BACKGROUND

Under the supervision of Drs. Harvy Joy Liwanag and Sarah De los Reyes of the Ateneo
School of Medicine and Public Health (ASMPH), Barlisan, Adel Karlo, Bueno, Pauline
Lourdes, Laurel, Juan Miguel Jr., Mangaoang, Czarina Dianne, Parungo, Manuel Karlo,
Rafael, Jeffrey Celso Mari and Ruby, Maria Franchina, 3rd year medical students at the
ASMPH are conducting research on pulmonary tuberculosis treatment and depression. The
purpose of this interview is to help the researchers study if there is an association between
pulmonary tuberculosis treatment and depression and if deemed positive, appropriate
recommendations can also be suggested. The study will be conducted from June 15 to July
31, 2015, and will include 1024 participants.
B. PROCEDURES
If I agree to participate in this research study, the following will occur:
I will be asked to participate in answering a survey questionnaire (PH-9) that will take a
maximum of ten minutes to accomplish.
C. RISKS

Risks: There are no known foreseeable risks or discomforts involved in participating in

this study.

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Confidentiality: The records from this study will be kept as confidential as possible. No
individual identities will be used in any reports or publications resulting from the study. All
summaries and results will be given codes and stored separately form any names or
other direct identification of participants. Research information will be kept locked in files
at all times. Only the research personnel will have access to the files and the audiotapes
and only those with an essential need to see names will have access to that particular
file. After the study is completed and all data has been transcribed from the tapes, the
tapes will be held for one year and then destroyed.

D. DIRECT BENEFITS
There will be no direct benefit to me from participating in this research study.
E. ALTERNATIVES
I am free to choose not to participate in this research study.
F. COSTS
I am free to choose not to participate in this research study.
G. QUESTIONS
I have spoken with Manuel Karlo Parungo or Adel Karlo Barlisan about this study and have had
my questions answered. If I have any further questions about the study, I can contact
asmph2018_23@gmail.com. Should you wish that you mail inquiries regarding the study, the
address is Ateneo School of Medicine and Public Health, Don Eugenio Lopez, Sr. Medical
Complex, Meralco Compound, Ortigas Avenue, Pasig City.
H. CONSENT
I have been given a copy of this consent form to keep.
PARTICIPATION IN RESEARCH STUDY IS VOLUNTARY. I am free to decline to participate
in this research study, or I may withdraw my participation at any point without penalty.
My decision whether or not to participate in this research study will have no influence on
my present or future status at the school I am presently studying in.
FULL PRINT NAME AND SIGNATURE OF
PARTICIPANT:
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DATE:
Statement by the researcher/person taking consent
I confirm that the participant was given an opportunity to ask questions about the study, and all
the questions asked by the participant 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.
A copy of this ICF has been provided to the participant.
FULL PRINT NAME AND SIGNATURE OF
RESEARCHER:
DATE:

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