APPENDIX ICorrelation of Gluteus Medius Strength among Flat-Footed Patients Aged 14-40

College of Affiliation: University of Santo Tomas, College of Rehabilitation Sciences, Physical Therapy Department

Investigators: Bolaños, Jean Atria., Ceniza, Jan Emmanuel., Lozada, Elmer Luigi., Pablo, Ceara Mei., Sinson, Clarice., Tuliao, Timothy John.

Contact Numbers of Primary Investigators:Clarice Sinson: 09275790405 / 9263525Jean Atria Bolaños: 09228675667

Advisers: Fernandez, Roxanne MSPT, PTRP. Nava, Jordan PTRP

INFORMED CONSENT FORM

An informed consent form for both males and females aged 14-40 whom we are inviting to participate in the experimental study entitled: Correlation of Gluteus Medius Strength

among Flat Footed Patients aged 14-40.

Greetings!We are graduating Physical Therapy students under the College of Rehabilitation Sciences of the University of Santo Tomas and we are currently undertaking a research-study on the “Correlation of Gluteus Medius Strength among Flat footed patients aged 14-40”.

Purpose of the Research: To determine if individuals with flat-foot would present weakness in hip abductor muscle strength

Conduct of the Study: Participants will have to answer a questionnaire and assessed through Feiss Line, X-ray, Manual Muscle Test, Hand Held Dynamometer, Trendelenburg test and to Vicon 2D Motion Analyzer to validate if there are qualified in the study.

Participant Selection: We are inviting all 14 - 40 years old who are flat-footed to participate in the research on the Correlation of Strength of Gluteus medius of Flat-Footed Patients in the affiliated centers of the College of Rehabilitation Sciences, University of Santo Tomas.

Voluntary Participation: Your participation in this study is voluntary and may withdraw anytime from the study for any reasons. During the course of the study, the participants will make at least three meetings with the researchers, two of these will be at St. Martin de Porres building in University of Santo Tomas for assessment using Feiss Line, Manual Muscle Test, Hand Held Dynamometer, Trendelenburg Test and Vicon 2D Motion Analyzer and the other one visits will be at the hospital chosen by the researchers where the x-ray would be done to ensure objectivity of results.

Benefits for the Participants: A better understanding that flat-foot has an effect in the weakness of hip abductor muscle strength and this would give off better treatment

strategies for individuals with flat-foot. The participants would also benefit from having free diagnosis by a doctor as to whether they are flat footed or not.

Risks for the Participants: There is small amount of risk with exposure to radiation but the amount of radiation generated during a foot x-ray is too small to cause harm.

Compensation: All procedures, transportation fees, food and miscellaneous fees needed for the study will be provided by the researchers

Confidentiality: The researchers ensure the confidentiality of the participants’ identity and records. Details that will be collected from you will only be accessible to the researchers of the study. Reference numbers rather than your full names will be used in the data presentation. The participants will be informed of the results of the research study.

If you have any questions or concerns about the research or any related matters, you may contact Clarice Sinson at 09275790405/ 9263525 or e-mail her at clasinson@gmail.com.Thank you very much,

Sincerely yours,

_______________________

Clarice Sinson09275790405/ 9263525clasinson@gmail.com

Noted by:

___________________________ ____________________________Roxanne Fernandez, MSPT, PTRP Jordan Nava, PTRP

CONSENT FORM

I have read and understood the above information and have been given the

opportunity to consider and ask questions on the information regarding the involvement

in the study. I have spoken directly to the investigators of the study who have answered

to my satisfaction all my questions. I have received a copy of this Participant’s

Information and Informed Consent Form. I hereby voluntarily agree to participate.

Participant’s Signature:

______________ ________________ __________

Printed Name of Participant Signature of Participant Date

_________________________ ___________________ __________

Printed Name of Legal Guardian Signature of Witness Date

Medical Clearance (if needed only):

I, undersigned, certify that the best of my knowledge, the participant signing this consent form has read above information sheet fully, that this has been carefully explained to him/her, and that he/she clearly understands the nature, risks, and benefits of his/her participation in the study.

Physician’s Signature:

______________________           __________________       _________

Printed Name of Physician           Signature of Physician                    Date

CONSENT FORM FOR MINOR

I have read and understood, with the assistance of my legal guardian, the above information and have been given the opportunity to consider and ask questions on the information regarding the involvement in this study. I have spoken directly to the investigators of this study who have answered to my satisfaction all my questions. I have received a copy of this Participant’s Information and Informed Consent Form. I hereby voluntarily agree to participate.

Minor-Participant’s Assent:

__________________ _______________ ________Printed Name of Minor Signature of Minor Date

_________________________ _________________ ________Printed Name of Legal Guardian Signature of Guardian Date

Witness:

__________________ _________________ ________Printed Name of Witness Signature of Witness Date