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Questionnaire and COnsent Form

The consent form is requesting participants for a study on management strategies for type 2 diabetes patients being conducted by Xenita Vera L. Pitos. It informs potential respondents that the survey will take 15-20 minutes, their answers will be kept confidential, and they can stop the interview at any time. It asks respondents to sign to agree to participate and provides space to do so, along with certifying their understanding of the study and consent to be contacted for clarification. The attached questionnaire then asks respondents for their profile information like age, sex, civil status, dependents, education level, occupation, and monthly income to participate in the study.

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Venice
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2K views

Questionnaire and COnsent Form

The consent form is requesting participants for a study on management strategies for type 2 diabetes patients being conducted by Xenita Vera L. Pitos. It informs potential respondents that the survey will take 15-20 minutes, their answers will be kept confidential, and they can stop the interview at any time. It asks respondents to sign to agree to participate and provides space to do so, along with certifying their understanding of the study and consent to be contacted for clarification. The attached questionnaire then asks respondents for their profile information like age, sex, civil status, dependents, education level, occupation, and monthly income to participate in the study.

Uploaded by

Venice
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CONSENT FORM

Dear Respondents,

Greetings!

I am Xenita Vera L. Pitos, an employee of University of Bohol, is hereby conducting a


research entitled: Management on Treatment Modalities among Type II Diabetes Mellitus
Patients. The focal objective of my study is to explore on the management strategies
employed by Type II Diabetes Mellitus patients.

In line with this, I would like to request your participation by taking part of this study as
the research respondents. The survey will take approximately 15-20 minutes. If you feel
uncomfortable in answering the questions being asked to you, you may stop the interview at
any moment. Rest assured that the information you provided will be kept with high
confidentiality. Please sign the space provided below if you agree to participate the said
survey.

Thank you and more power!

Sincerely,

XENITA VERA L. PITOS, RN-MAN LPT


Researcher

I hereby certify that I fully understand the purpose of this research and I freely give my
consent to the researcher to include me in the survey.

I further give my consent to be contacted for clarification/interview regarding my


answers to these research questions.

____________________________ __________________________
Signature Date
QUESTIONNAIRE

The researcher is asking your wholehearted and honest answers of the questions. Rest
assured that all your answers will be treated strictly confidential.

Directions: Tick ( ) on the blank of your corresponding answer.

I. Respondent’s Profile

Age

20 – 25 years old 46 – 50 years old


26 – 30 years old 51 – 55 years old
31 – 35 years old 56 – 60 years old
36 – 40 years old 61 – 65 years old
41 – 45 years old 66 years old and above

Sex

Male Female

Civil Status

Single Widow/Widower
Married Separated

If married, number of dependents:

1 child 4 – 5 children
2 – 3 children 6 ore more children

Highest Educational Attainment

Elementary Level/Graduate Master’s Units/Degree Holder


High School Level/Graduate Doctorate Units/Degree Holder
College Level/Graduate
Occupation

None
Self-Employed (Businessmen)
Government Employee
Private Employee
Retiree

Monthly Income

P3, 000 – P6, 999 Female


P7, 000 – P10, 999
P11

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