Informed Consent Form (Annex A1) - Koronadal

Annex “A1”
Room #_____Seat #______

Temp______
Professional Regulation Commission
INFORMED CONSENT
ON THE POTENTIAL RISK ASSOCIATED WITH TAKING THE
LICENSURE EXAMINATION
(profession)
PLEASE READ THIS DOCUMENT CAREFULLY.
You are given this informed consent form because the Professional Regulation
Commission (PRC) and Professional Regulatory Board of
(profession)
encourage your participation in the licensure examination. All known
(profession)
precautions are taken to safeguard all examinees, but the PRC/PRB cannot guarantee
your absolute safety from any potential source of infection. You are asked to sign this
form to signify your consent to participate in the said activity despite the potential risks.
INFORMATION SHEET
Introduction and Purpose of the Activity
On March 11, 2020, the World Health Organization (WHO) has declared COVID-19 a
pandemic with confirmed cases nearing twenty million (20,000,000) around the world
without yet any sign of decline. The Philippines was no exception. With the continuing
upsurge of recorded cases per day, the country needs to reinforce the number of its
health workers to fight this pandemic.
Following the request of different professional organizations and other stakeholders, the
Commission is prepared, although with greater precaution this time, to discharge its
mandate of conducting the licensure examinations.
Procedure
The PRC is instituting health safety protocols to ensure the safety of all examinees, as
well as the PRC personnel involved in the conduct of the examination. Listed below are
the established best practices and their respective percentages of risk reduction of
CoVID-19 transmission:
• 95% if you use N95 mask, 76% for surgical mask

• 67% if you wear face shield
• 90% if there is distance of 1 meter, 92% if 2 meters
(For a more detailed information, please refer to PRC Memorandum Order No. __ s.
2020 entitled “STRICT HEALTH PROTOCOLS TO BE OBSERVED IN THE CONDUCT
OF LICENSURE EXAMINATIONS DURING THE COVID-19 PANDEMIC”).
Risks
By participating in the examination, it is possible that you will be exposed to COVid-19.

There is, for example, a chance that you might contract the virus while transporting to
the venue. Although reduced in number with the mandatory minimum distances
between examinees, you will still be staying in an enclosed room together with other
examinees for several hours. Nonetheless, we assure you that the PRC will implement
all known safety measures prescribed by the Omnibus Guidelines of the Inter-Agency
Task Force (IATF) and the recommendations of the scientific community to reduce the
possibility of infection.
You still have the responsibility to weigh the risks against the benefits. Your judgment
and discernment will guide you in deciding whether to take the licensure examination or
not.
Alternative to Participating in the Licensure Examination
As a rule, all examinees who fail to take the licensure examination to be considered
absent and will need to re-apply and pay for the next exam. By way of exemption, if you
fail to participate in the examination because of health reasons, travel restrictions or any
other valid reasons, please inform the concerned Regional Office of your place of
examination within the week prior to the exam. You will be allowed to take the next
scheduled licensure examination, provided that the requirements mentioned herein are
complied with.
Post Examination Requirement

Fifteen (15) days, after the examination, we require the examinees to submit a post-
exam health status update (Annex C) to help the examinees and future conduct of
licensure examinations. The form can be downloaded from the website (prc.gov.ph) and
this can be sent through the official email address of the Regional Office where you take
your licensure examination. Please provide the information as accurately as possible.
FOR PRC KORONADAL:

Please send the accomplished Annex A3 to: health.prc12@gmail.com
ON
Agreement to Participate: If you agree to participate in the licensure exam, please

indicate so by signing on the specified space below.
Thank you.
CERTIFICATE OF CONSENT
I, , of legal age, residing at

( Last Name, First Name , Middle Name)
have read and understood the

(Address)
information and potential risks explained in this form. Despite such risks, I agree to take
the Licensure Examination on
( Profession) ( Date/s of Examination)
to be administered by the Professional Regulation Commission. I do hereby confirm and

declare that I am participating in this event on my own free will and volition
In relation thereto, I hold PRC, entirely free from any liability or responsibility in the
event that I contract CoVID-19 during the period of the Licensure Examination on
.
( Date/s of Examination)
Name of Examinee and Signature Date
Name of Witness and Signature Date

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Annex “A1”

Room #_Seat #__

PLEASE READ THIS DOCUMENT CAREFULLY.

Introduction and Purpose of the Activity

• 95% if you use N95 mask, 76% for surgical mask

By participating in the examination, it is possible that you will be exposed to COVid-19.

Alternative to Participating in the Licensure Examination

Post Examination Requirement

FOR PRC KORONADAL:

Agreement to Participate: If you agree to participate in the licensure exam, please

I, , of legal age, residing at

have read and understood the

to be administered by the Professional Regulation Commission. I do hereby confirm and

Name of Examinee and Signature Date

Name of Witness and Signature Date

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