BCREC - 05

Rev. 01 / November 6, 2017

Brokenshire College Approved by:
Madapo Hills, Davao City, 8000, Philippines
Tel No.(082) 227-2105 local 154/ Fax No. (082) 227-2105 Control No.: _______________

Form E. Informed Consent Form when Questionnaires are Used

Brokenshire College Research Ethics Committee

Madapo Hills, Davao City

IMPORTANT: All fields must be completed.

Research Title: Preparedness and Competencies of Nursing Students on

Standard Health Precautions in Handling Infectious Diseases

Faculty Researchers: _____________________ _______________________

_______________________ ________________________

Student Researchers: Custodio, Nicomedes III Legaspi, Mei Kaiza

Deliña, Merry Joy Abulag Sharmine
Martel, Christine Cadayona, Exil
Name of Sponsor (if applicable): _____ _____________________________________________
Date Submitted: _______________
Date Received: _______________

The information sheet and consent form C NC N/A

a Describe the nature and purpose of the questions to be asked
b State that the participants is free to not answer any question
c Clearly states, where applicable, that some of the questions may prove
embarrassing for the participant
d Clearly states, where applicable, that the interviews (in-depth or focus group
discussions) are likely to be audio or video taped.
e Clearly mention, where applicable, how and for how long the tapes/ files are going
to be stored

Legend: C – Complied NC – Not Complied N/A – Not Applicable

Submitted by

Name Signature Name Signature

Custodio, Nicomedes III _______________ Legaspi, Mei Kaiza T ______________

Deliña, Merry Joy _______________ Abulag, Sharmine ______________
Martel, Christine _______________ Cadayona, Exil _______________

Endorsed by/ Recommended by: Mrs.Visminda B. Batoy RN, MN, COHN

Research Adviser/ Mentor

Date Filed: _______________