INFORMED CONSENT

Dengan segala hormat, seperti yang dinyatakan dibawah ini:

Nama : Omprakash Nanda Kumar

Universitas : Universitas Udayana

Fakultas : Kedokteran

Program Studi : Kedokteran Umum

Semester : 8 (delapan)

NIM : 1402005180

Alamat : Jalan Alor, No.10, Denpasar

Nomor HP : +6281999520143

Tujuan saya membuat kuesioner ini adalah untuk penelitian saya yang bertajuk,
Awareness of Male Infertility among Students in Udayana University. Sehubungan dengan
itu, saya memohon kerjasama saudara/saudari dengan segala kerendahan hati untuk
meluangkan waktu untuk menjawab pertanyaan dalam kuesioner ini. Diharapkan jawaban yang
diberi lengkap dan jujur agar dapat membantu penelitian saya. Segala informasi yang
disertakan dalam kuesioner ini akan dijaga kerahasiaannya.

Saya berharap sungguh partisipasi saudara/saudari dalam penelitian saya ini.

Sekian,terima kasih.

Partisipan, Peneliti,

------------------------------ -------------------------------

(Nama: ) (Nama: Omprakash Nanda Kumar)

PART A “Basic Details”. (Please answer all and all answers must be based on the truth)

Name :

Gender :

Batch :

Class :

Part B “Male Infertility’”. (Please answer all and all answers must be based on the truth)

1. Do you know what is male infertility? (YES / NO )

2. In general, how knowledgeable would you say you are about male infertility ?

a) Not at all knowledgeable

b) Slightly knowledgeable
c) Very knowledgeable

3. From which sources have you gained knowledge about men’s fertility?

a) Books
b) Doctor
c) Friends/family
d) Medical apps on smartphones or tablets

4. To what extent are you interested in learning more about male reproduction and fertility
problems, including the risk factors and other medical conditions/illnesses associated with it
and treatment for it?

a) Not at all interested

b) Somewhat interested
c) Very interested
5. To the best of your knowledge, to what extent do male factors contribute to fertility
problems?

a) Does not cause fertility problems

b) Somewhat causes fertility problems
c) Major cause to fertility problems

6. How concerned are you about your own fertility at this time?

a) Not at all concerned

b) Slightly concerned
c) Very concerned

7. In the future, would you like to have biological children?

a) Yes
b) No
c) Undecided

8. Regardless of your answers in the previous question, please rate the extent to which you
consider each of the following to be a factor that affects a man’s fertility.

a) Age (more than 45 years old)

b) Alcohol consumption (more than 10 drinks a week)
c) Cancer treatment (such as radiation or chemotherapy)
d) Coffee (>4 cups a day)
e) Smoking
f) Frequent masturbation
g) Frequent sexual relations
h) Frequent use of a laptop on your lap
i) Genetic abnormality
j) Hernia repair
k) High cholesterol
l) Lack of regular exercisea
m) Long-term use of antibiotics
n) Long-term use of steroids
o) Migraines
9. Regardless of your answers in the previous question, please rate the extent to which you
consider men with fertility problems to be at risk of each of the following medical
conditions/illnesses.

a) Arthritis
b) Being underweight
c) Cardiovascular disease (heart disease, high blood pressure)
d) Depression
e) Diabetes
f) Fever
g) Insomnia
h) Obesity
i) Prostate cancer
j) Sexually transmitted infections

10. Please indicate whether or not you are aware of each of the following treatment options
available to men who experience fertility problems so they may be able to father biological
children.

a) Acupuncture
b) Antibiotics
c) Banking sperm
d) Gonadotropin treatment
e) Herbal remedies (such as ginseng, etc.)
f) IVF
g) ICSI
h) IUI
i) Testicular sperm extraction (TESE)
j) Treatment for erectile dysfunction
k) Varicocele repair
l) Vasectomy reversal