APPENDIX I

Correlation 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: Bolaos, Jean Atria., Ceniza, Jan Emmanuel., Lozada, Elmer Luigi.,
Pablo, Ceara Mei., Sinson, Clarice., Tuliao, Timothy John.
Contact Numbers of Primary Investigators:
Clarice Sinson: 09275790405 / 9263525
Jean Atria Bolaos: 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 researchstudy 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 FlatFooted 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 Sinson
09275790405/ 9263525
clasinson@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 Participants
Information and Informed Consent Form. I hereby voluntarily agree to participate.

Participants Signature:
______________

________________

Printed Name of Participant

Signature of Participant

_________________________

___________________

Printed Name of Legal Guardian

Signature of Witness

__________
Date
__________
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.

Physicians Signature:
______________________
_________
Printed Name of Physician
Date

__________________
Signature of Physician

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

Minor-Participants Assent:

__________________
Printed Name of Minor

_______________
Signature of Minor

_________________________
Printed Name of Legal Guardian

_________________
Signature of Guardian

________
Date

________
Date

Witness:
__________________
Printed Name of Witness

_________________
Signature of Witness

________
Date