C O L L E G E O F P H A R M A C Y

U n i v e r s i t y o f B o h o l
CP Office, Second Floor UB Administration Building,
Dr. Cecilio Putong Street, 6300 Tagbilaran City, Bohol,
Philippines ☎ (038) 411-3484 (local 804)

Informed Consent Form

Informed consent from for: Community Pharmacist in Tagbilaran City

Name of Principal Investigator:

CUSTODIO, LISSEL B., FAJARDO, ZIALME A., LIM, KISSY MAE B., PALITEC,
JONATHAN C., PALOMARES, YVONE., PON, SHEMILYN., RAUT, ALYANNA
MARIELLE M.

Name of Organization: University of Bohol – College of Pharmacy

Name of Project: SMOKING CESSATION KNOWLEDGE, AWARENESS AND

PERCEPTION AMONG COMMUNITY PHARMACISTS IN TAGBILARAN CITY,
BOHOL: SURVEY OF UB PHARMACY STUDENT

We, the 4th year students of the College of Pharmacy conducting a study
regarding Community Pharmacist’s knowledge, awareness and perceptions
about smoking cessation as one of our requirements for the degree Bachelor
of Science in Pharmacy. In line with this, we would like to request your
participation by answering our survey. This study aims to measure the
Community Pharmacist’s knowledge, awareness and perceptions towards
smoking cessation i9n order to better understand the existing stigma that is
a barrier to delivering professional service.

This survey consists of three parts: demographic data, knowledge questions,

awareness questions and perception questions. The respondents should
answer all questions to the best of their ability. We have chosen you be one
of our respondents because you are one of providers of smoking cessation
services. Thus, you are suited to answer this survey. Once again, we request
your participation in our study as it would greatly help us to achieve our
goal. However, you may not choose to participate. The questionnaire will be
given to chain drugstore’s in Tagbilaran, City, Bohol. The survey will take 1-
20 minutes to answer. By choosing to participate, you will help in
advancement of the pharmacy profession and assess your own knowledge in
smoking cessation.

All your answers and information will be seen only by the researchers and
kept confidential from other persons. The findings of this research will be
made available to all interested individuals who intended to know more
about topic. Again, your participation must be voluntary and you may
withdraw from the study at any time.

You may contact Ms. Alyanna Marille M. Raut at 09152321612 for any
questions or concerns regarding the matter.

CERTIFICATE OF CONSENT

I have read the foregoing information, or it has been read to me. I have had
the opportunity to ask questions about it and any questions I have been
asked have been answered to my satisfaction. I consent voluntarily to be a
respondent in this study.

Name of respondent:

Signature of respondent:

Date:

STATEMENT OF THE RESEARCHER OR PERSON TAKING CONSENT

I confirm that the participant was given an opportunity to ask questions

about the study and all the questions have been answered correctly to the
best of my ability. I conform that individual has not been coerced and the
consent has been given freely and voluntarily.

Name of researcher:

Signature of researcher:

Date: