MARTINEZ MEMORIAL COLLEGES

COLLEGE OF NURSING 198 A. Mabini St., Maypajo, Caloocan City

Informed Consent to Participate In a Research Study Title of Research: Preoperative Anxiety Level of Patients Who Will Undergo Ambulatory Minor Surgery in a Medical Center in Metro Manila: Basis for Formulating Guidelines to Minimize Preoperative Anxiety Alcala, Arrianne Corsame, Roxan Dagalea, Ma. Eiza Rona Ganzan, Jenyza Lusung, Lea Rubio, Juan Carlo Sabili, Janen Sareno, Ma. Elisa Torres, Amicy Grace Vidal, Monica

Name of Researchers:

Phone Number of Researcher: 09169846588 A. PURPOSE OF THE STUDY Under the approval of the Research Director Neil G. Cabbo, MSN and research adviser Romeo Q. Rivera Jr., RN, MAN, the Level IV nursing students is conducting a series of research on preoperative anxiety of patients undergoing ambulatory minor surgeries. The aim of the study is identify the level of anxiety of patients in the preoperative phase that will undergo Ambulatory Minor Surgery in a Medical Center in Metro Manila, Basis for formulation of guidelines to minimize preoperative anxiety. B. PROCEDURES If I agree to participate in this research study; 1. I will be asked to answer a semi-structured interview consuming at least 15 minutes to 30 minutes of my time. 2. I will be asked of my age and gender. 3. I will provide answers on the questions that will assess my level of anxiety. 4. If I agree to participate in this study, transcript of data will be compiled for research purposes. C. RISKS There are no known foreseeable risks or discomforts involved in participating in this study aside from the long duration of interview process. Confidentiality: The records from the study will be kept confidential as possible. No individual identities will be used in any reports or publications resulting from the study. All transcripts and summaries will be given codes and stored separately from any names or other direct identifications of the participants. Research information will be kept locked at all times. Only the researchers will have access to the files and only those with essential need to see the date will have access to that particular file. After the

MARTINEZ MEMORIAL COLLEGES

COLLEGE OF NURSING 198 A. Mabini St., Maypajo, Caloocan City
data are completed and all the recorded data have been transcribed to computer files, the interview schedules and hard copy will be held for one year and then it will be destroyed. D. DIRECT BENEFITS There are no direct benefits that I will gain form the study. Anticipated benefits will be the deeper understanding and knowledge regarding preoperative anxiety during minor surgeries after the analysis and dissemination of the study results. E. ALTERNATIVES I am free to choose not to participate in the study. F. COSTS There will be no costs to me as a result of taking part in this research study. G. WAYS TO OBTAIN STUDY RESULTS I may obtain study results from the manuscript that will be given in Tondo Medical Center after the completion of the study of the researchers may give me a hard copy of the findings or send me a soft copy in my email address: _____________________ H. COMPENSATION I will not be receiving any monetary compensation in this study. The compensation that can be given will be the knowledge that I will gain after knowing the results of the study, after its completion as stated in the benefits of the study. I. QUESTIONS If I have any further questions bout the study, I can contact the researchers by calling 0916-9846-588 or write to the Office of Research and Extension Services, Martinez Memorial Colleges, 198 A. Mabini St., Maypajo Caloocan City. J. CONSENT I have 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 may withdraw my participation at any point without penalty. My decision whether or not to participate will have no influence in anything in this study. Signature _________________________ Research Participant Signature _________________________ Researchers Date ________________________