Informed Consent and Survey Questionnaire for Female Physicians
Part I: Information Sheet
I am Dr. Lilybell Victoria E. Estepa, a second year adult cardiology fellow-in-training at the University of Santo Tomas Hospital.
I, together with Dr. Aileen Cynthia F. De Lara, are conducting a survey about female physicians’ perceptions, knowledge, personal practices and counselling practices with regard to lifestyle and cardiovascular diseases.
You will be asked to provide information on your demographics, some health-related lifestyle habits, some personal preventive measures, your awareness of primary CVD prevention method and your CVD counselling practice. There are 40 questions in total. We estimate you may need up to 15 minutes or slightly more to complete the survey. Please try and answer all the questions if you can.
Your participation is entirely of your own free will and you can withdraw from this survey at any time you like without explanation. You have the right to refuse to answer any question you do not want to respond to.
Any information collected will remain confidential. Your name will not be attached to any published results. Only I and Dr. De Lara will have access to the data.
Thank You. Mabuhay, Pusong Pinay!
Part II: Certificate of Consent
I have read the foregoing information and I have had the opportunity to ask questions about it and any questions that I have asked have been answered to my satisfaction.
I consent voluntarily to join as a participant in this survey.
Yes, If you answer Yes, Please answer all the questions in the next section
No, If you answer No, You can submit the form after this section
Full Name (Last, First, MI)
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