1 
' MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• Adult Patient or • Parent, for Minor Patient 
continuation: 
page_l^oflL.pr 
STUDY NUMBER: 
OTHER PERTINENT INFORMATION 
1 . Confidentiality. When results of a study such as this are reported in medical journals or at meetings, the identificat 
of those taking part is withheld. Medical records of Clinical Center patients are maintained according to current le 
requirements, and are made available for review, as required by the Food and Drug Administration or other authori: 
users, only unaer the guidelines established by the Federal Privacy Act. 
2. Policy Regarding Research-Related Injuries. The Clinical Center will provide short-term medical care for any phys 
injury resulting from your participation in research here. Neither the Clinical Center nor the Federal government" 
provide long-term medical care or financial compensation for such injuries, except as may be provided through whate 
remedies are normally available under law. _ _ 
3. Payments. If you are a patient, you are not paid for taking part in NIH studies. Exceptions for volunteers will 
guided by Clinical Center policies. 
. 
4. Problems or Questions. Should any problem or question arise with regard to this study, with regard to your rig 
as a participant in clinical research, or with regard to any research-related injury, you should contact the princi 
investigator, Ur. Steven Rosenberg , or these other staff members also involved in this stu 
; ; 
Building 10 , Room 2B42 Telephone: (301) 496-4164 
National Institutes of Health 
Bethesda, Maryland 20205 
5. Consent Document. It is suggested that you retain a copy of this document for your later reference and perso 
records. 
COMPLETE APPROPRIATE ITEM BELOW, A or B: 
A. Adult Patient's Consent. 
1 have read the explanation about this study and 
have been given the opportunity to discuss it and 
to ask questions. 1 hereby consent to take part in 
this study. 
B. Parent’s Permission for Minor Patient. 
1 have read the explanation about this study ; 
have been given the opportunity to discuss it ; 
to ask questions. 1 hereby give permission for 
child to take part in this study. 
(Attach NIH 2514-2, Minor’s Assent, if applicabl 
Signature ol Aauii Patient & Date S^gneo 
Signature ol Parent(s) & Date Signea 
(if other than parent, specify relationship) 
Signature ol Investigator & Date Signea 
Signature of Witness & Oate Signed 
■ 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL 
RESEARCH STUDY 
Recombinant DNA Research, Volume 15 
[93] 
