Informed Consent Form for Emilio Aguinaldo College Medical Students are inviting to participate

in research
“Use of Surgical glue Versus Traditional Wound Closure Methods in Reducing Risk of
Post-Operative Infection in Laparoscopic Surgery: A Cross Sectional Study”

This Informed Consent Form has two parts:

• Information Sheet (to share information about the study with you)
• Certificate of Consent (for signatures if you choose to participate)

Part I: Information Sheet

Introduction
Surgical glue (tissue adhesive) is used to close both major and minor wounds, such as
lacerations, incisions made during laparoscopic surgery, and wounds on the face and
groin. surgical glue costs more than sutures. Some people are allergic to it.
Surgical site infection is an infection that occurs after surgery in the part of the body where
the surgery took place. Surgical site infection can sometimes be superficial infections
involving the skin only. Other surgical site infections are more serious and can involve
tissues under the skin, organs, or implanted material.
Laparoscopic surgery is a type of surgery in which small incisions are made in the
abdominal wall through which a laparoscope and other instruments can be placed to
permit structures within abdomen and pelvis to be seen.

Purpose of the research

The purpose of this study is to perceive if the surgical glue is more effective than traditional
wound closure in reducing the risk of post-operative infection in laparoscopic patient.

Type of Research Intervention

This research will involve your participation in answering a questionnaire that will take 10
to 15 minutes of your time.

Procedures
A. We are asking you to help us by answering the questionnaire truthfully and completely.

B. Please fill out a survey which will be provided by the group and will be collected
afterwards by the group. The information recorded is confidential, your name is not being
included on the forms, only a number will identify you, and no one else except the group
with access to the information will have access to your survey.

Risks
There are no risks that will harm you in answering the questionnaire, but the information
that you will be providing can be assured that it will be kept confidential.
Benefits
The result of this research may benefit both medical practitioners and patients to prevent
surgical site infection, which decreases need for hospital care and lessen health care
costs.

Confidentiality
Please do NOT write any identifying information on your questionnaire. For the purposes
of this research, your comments will not be anonymous unless you request that they be.
Every effort will be made by the researcher to preserve your confidentiality. Participant
data will be kept confidential except in cases where the researcher is legally obligated to
report specific incidents.

Who to Contact
You have the right to ask any questions you may have about this research. If you have
questions, complaints or concerns related to this research, contact (contact person)

Part II: Certificate of Consent

For the Participant:

I have been invited to participate in research (title)

I have read the foregoing information.

I have had the opportunity to ask questions about the study and have been answered to my
satisfaction.

I am giving my consent to participate in this study.

By signing herein below, I do hereby expressly agree to the privacy policy of Emilio Aguinaldo
College (EAC) and the data privacy laws of the Philippines and giving my consent to the EAC's
collection, use, storage, and processing of my personal data and agree to hold the EAC, its
affiliates, its directors, officers, employees, consultants, advisers, agents, students and
authorized representatives, free and harmless from any actions, damages and suits of whatever
kind and nature in relation with my confirmation, declaration and consent hereof.

CONFORME:

Participant’s Name: ____________________________

Signature: ____________________________________ Date:

______________________

For the Researcher:

I have accurately given the information, answered any question and verified that the participant
had understood the study. The participant verified that he/she had understood that a survey
type of study will be done regarding burnout, coping mechanism, and the quality of life of allied
health services students in EAC.

I confirmed to the participant that he/she understands that this study is purely voluntary and
there is no coercion into giving the consent. A confirmation was also established that he/she will
have the right to discontinue participating in the study anytime. A copy of this informed consent
has been provided to the participant.

CONFORME:

Printed Name of Researcher: ____________________________

Signature of Researcher: _______________________________ Date: ________________

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