Irb Form 004 v2 Inf Ormed Consent Form Final Revised

University of Cagayan Valley
Institutional Review Board

Balzain Highway, Tuguegarao City
Cagayan, Philippines
Doc. No 004
INFORMED CONSENT Rev. No 002

(Research/Thesis/
Dissertation) Effectivity Date 0121
Page 1 of 3
You are being asked to take part in a research study. Before you decide to participate in this
study, it is important that you understand why the research is being done and what it will involve.
Please read the following information carefully. Please ask the researcher if there is anything that
is not clear or if you need more information.
TITLE OF STUDY
“Behavioral Manifestation and Coping Strategies of Students Belonging to Dysfunctional
Family”
PRINCIPAL INVESTIGATOR
Name: Editha Ariola Sabado
Department: School of Liberal Arts and Teacher Education
Address: Maguirig, Solana, Cagayan
Phone: 0905-358-6210
Email: [email protected]
PURPOSE OF STUDY
This study aims to determine the behavioral manifestation and coping strategies of students
belonging to dysfunctional family due to the marital separation of their parents who are 18 years
old and above, female and male, single or married that are officially enrolled in the different
courses and year level at the University of Cagayan Valley in the school year 2023-2024.
TIME: Your participation in the study will take about 15 minutes to answer the given
questionnaire.
RISKS
There is no foreseeable risks in conducting the study. You may decline to answer any or all the
questions, and you may terminate your involvement at any time if you choose.
Doc. No 004

(Research/Thesis/
Page 2 of 3
BENEFITS
There will be no direct benefit or compensation for you from participating in this research study.
This research will benefit parents, students, teachers, school administrators, community,
researchers, and future researchers as a guide in greater advance to recognize the different
behavioral manifestations and coping strategies of students belonging to dysfunctional family. It
may also serve as a reference for future researchers to guide their students and evaluate the
behaviors of the students that belong to a dysfunctional family, which will help them know how
to deal with youth and will raise awareness about the experiences of students with dysfunctional
families and extend sympathy rather than judgments and discrimination.
CONFIDENTIALITY
Your privacy and confidentiality are of utmost importance in this research study. All information
collected during the study will be kept strictly confidential and will only be accessible to the
research team. Your identity will be protected through the use of pseudonyms or pen name to
ensure anonymity. The data collected, including interview transcripts, survey responses, and any
other personal information, will be securely stored in locked filing cabinets. Only authorized
research team members will have access to this information. Your information will not be shared
with any third parties without your explicit consent. Any published results or reports will not
include any identifying information that could reveal your identity. Data collected during the
study will be retained for a specified period as required by ethical guidelines and regulations.
After this period, all data will be securely destroyed and burned.
CONTACT INFORMATION
If you have questions at any time about this study, or you experience adverse effects as the result
of participating in this study, you may contact the researcher whose contact information is
provided on the first page. If you have questions regarding your rights as a research participant,
or if problems arise which you do not feel you can discuss with the Primary Investigator, please
contact the University of Cagayan Valley - Institutional Review Board (UCV_IRB) at (078) 377
- 4617 local 227
Doc. No 004

(Research/Thesis/
Page 3 of 3
VOLUNTARY PARTICIPATION
Your participation in this study is voluntary. It is up to you to decide whether or not to take part
in this study. If you decide to take part in this study, you will be asked to sign a consent form.
After you sign the consent form, you are still free to withdraw at any time and without giving a
reason. Withdrawing from this study will not affect the relationship you have, if any, with the
researcher. If you withdraw from the study before data collection is completed, your data will be
returned to you or destroyed.
CONSENT
I have read and I understand the provided information and have had the opportunity to ask
questions. I understand that my participation is voluntary and that I am free to withdraw at any
time, without giving a reason and without cost. I understand that I will be given a copy of this
consent form. I voluntarily agree to take part in this study.
Participant's signature ______________________________ Date __________
Investigator's signature _____________________________ Date __________

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University of Cagayan Valley

Institutional Review Board

INFORMED CONSENT Rev. No 002

INFORMED CONSENT Rev. No 002

INFORMED CONSENT Rev. No 002

Participant's signature ____________________ Date

Investigator's signature ___________________ Date

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