University of the Immaculate Conception

REC_FO_0057
Research Ethics Committee (REC)
Control No.: _________
Bonifacio Street, Davao City, Philippines

Ethics Informed Consent Form (ICF)

Informed Consent Form for : Teaching Behavior and 21st Century Skills as
Predictors of Student Engagement
Name of the Researcher(s) : S. Maria Magdalena Bano, RVM
Institution : Religious Of the Virgin Mary

INTRODUCTION

Telephone No. (082) 227-82-86 (loc. 211) ● Email Address: [email protected] Page 1 of 12
 University of the Immaculate Conception
REC_FO_0057
Research Ethics Committee (REC)
Control No.: _________
Bonifacio Street, Davao City, Philippines

You are invited to participate in a research study conducted by S. Maria Magdalena

Bano, RVM, at the University of the Immaculate Conception, because you fit the inclusion
criteria for informants of our study.

Your participation is completely voluntary. Please read the information below, and ask
questions about anything you do not understand, before deciding whether to participate.
Please take as much time as you need to read the consent form. You may also decide to
discuss participation with your family or friends.

If you decide to participate, you will be asked to sign this form. You will be given a copy
of this form.

Telephone No. (082) 227-82-86 (loc. 211) ● Email Address: [email protected] Page 2 of 12
 University of the Immaculate Conception
REC_FO_0057
Research Ethics Committee (REC)
Control No.: _________
Bonifacio Street, Davao City, Philippines

PURPOSE OF THE STUDY

This study aims determines if student engagement is influenced by teaching behavior
and 21st century skills of the junior high school students in East Nusa Tenggara,
Indonesia. It looks for answers to the following queries: What is the level of
teaching behavior, 21st century skills, and student engagement with their corresponding
indicators. Also, it aims to determine the significance of the relationship between
teaching behavior and student engagement; and 21st century skills and student
engagement as well as the significance of the influence of teaching behavior and 21 st
century skills towards student engagement.

STUDY PROCEDURES

Telephone No. (082) 227-82-86 (loc. 211) ● Email Address: [email protected] Page 3 of 12
 University of the Immaculate Conception
REC_FO_0057
Research Ethics Committee (REC)
Control No.: _________
Bonifacio Street, Davao City, Philippines

If you volunteer to participate in this study, you will be asked to participate by answering
the survey questionnaires which you can finish in less than 60 minutes.

POTENTIAL RISKS AND DISCOMFORTS

You may feel discomfort during the course of answering the questionnaires. You may opt
not to answer questions which make you feel any psychological or emotional distress, or
you can withdraw as a participant of the study if you feel that you cannot discuss the
information that is asked of you. The researchers value your participation and will place
your welfare as their highest priority during the course of the study.

POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY

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 University of the Immaculate Conception
REC_FO_0057
Research Ethics Committee (REC)
Control No.: _________
Bonifacio Street, Davao City, Philippines

This study can generate relevant information about teaching behavior and 21 st century
skills as predictors of student’s engagement. With this, practical recommendations may
be provided such as teacher training, teacher aids, as well as school support and policy
to enhance the teacher’s teaching behavior which could help raise the level of student
engagement. In relevance, findings of this study may help the Indonesian government
reach its goal to have quality education in 2025. Likewise, this study may serve best not
only the teachers, and school administrators but also the monitoring bodies of the
educational system in East Nusa Tenggara.

DATA PRIVACY AND CONFIDENTIALITY

I will keep your records for this study confidential as far as permitted by law reflected in
the Data Privacy Act of 2012. Any identifiable information obtained in connection with

Telephone No. (082) 227-82-86 (loc. 211) ● Email Address: [email protected] Page 5 of 12
 University of the Immaculate Conception
REC_FO_0057
Research Ethics Committee (REC)
Control No.: _________
Bonifacio Street, Davao City, Philippines

this study will remain confidential, except if necessary to protect your rights or welfare.
This certificate means that the researcher can resist the release of information about
your participation to people who are not connected with the study. When the results of
the research are published or discussed in conferences, no identifiable information will
be used.

VOLUNTARINESS OF PARTICIPATION AND RIGHTS TO WITHDRAW FROM THE

RESEARCH
Your participation is voluntary. Your refusal to participate will involve no penalty or loss
of benefits to which you are otherwise entitled. You may withdraw your consent at any
time and discontinue participation without penalty. You are not waiving any legal claims,
rights or remedies because of your participation in this research study.

Telephone No. (082) 227-82-86 (loc. 211) ● Email Address: [email protected] Page 6 of 12
 University of the Immaculate Conception
REC_FO_0057
Research Ethics Committee (REC)
Control No.: _________
Bonifacio Street, Davao City, Philippines

REIMBURSEMENT AND COMPENSATION

You will be given a token through your school which is a sign of gratitude for helping the
researcher in accomplishing the study.

INVESTIGATOR’S and ADVISER’S CONTACT INFORMATION

If you have any questions or concerns about the research, please feel free to contact the
researcher at the University of the Immaculate Conception, Bonifacio St., Davao City
through telephone number 227-8286 local 240 or mobile phone number 09053359623 or
through email at [email protected] ; or if you need to contact her adviser Prof.
DR. Edna T. Salva through her email address [email protected].

Telephone No. (082) 227-82-86 (loc. 211) ● Email Address: [email protected] Page 7 of 12
 University of the Immaculate Conception
REC_FO_0057
Research Ethics Committee (REC)
Control No.: _________
Bonifacio Street, Davao City, Philippines

RIGHTS OF RESEARCH PARTICIPANT

If you have questions, concerns, or complaints about your right as a research participant
or the research in general and are unable to contact the research team, or if you want to
talk to someone independent of the research team, please contact the University of the
Immaculate Conception Research Publication, and Innovation Center at 227- 82-86 local
211.

Telephone No. (082) 227-82-86 (loc. 211) ● Email Address: [email protected] Page 8 of 12
University of the Immaculate Conception
REC_FO_0057
Research Ethics Committee (REC)
Control No.: _________
Bonifacio Street, Davao City, Philippines

Telephone No. (082) 227-82-86 (loc. 211) ● Email Address: [email protected] Page 9 of 12
 University of the Immaculate Conception
REC_FO_0057
Research Ethics Committee (REC)
Control No.: _________
Bonifacio Street, Davao City, Philippines

RESEARCH PARTICIPANT’S CONSENT

I have read the information provided above. I have been given a chance to ask
questions. My questions have been answered to my satisfaction, and I agree to
participate in this study. I have been given a copy of this form. I can withdraw
my consent at any time and discontinue participation without penalty.

Page 10 of 12
Telephone No. (082) 227-82-86 (loc. 211) ● Email Address: [email protected]
 University of the Immaculate Conception
REC_FO_0057
Research Ethics Committee (REC)
Control No.: _________
Bonifacio Street, Davao City, Philippines

___________________________________ ______________________
Signature above Printed Name of Participant Date Signed

To be accomplished by the Researcher Obtaining Consent:

I have explained the research to the participant and answered all of his/her
questions. I believe that he/she understands the information described in this
document and freely consents to participate. (If in GROUP, be sure all members
affix their names and signature, too.)

Page 11 of 12
Telephone No. (082) 227-82-86 (loc. 211) ● Email Address: [email protected]
 University of the Immaculate Conception
REC_FO_0057
Research Ethics Committee (REC)
Control No.: _________
Bonifacio Street, Davao City, Philippines

_ S. MARIA MAGDALENA BANO, RVM _________________

Name of Person Obtaining Consent Date Signed

Page 12 of 12
Telephone No. (082) 227-82-86 (loc. 211) ● Email Address: [email protected]