IUPUI INFORMED CONSENT STATEMENT 
for 
PROJECT Retroviral -Mediated Gene Transfer of Bone Marrow Cells During 
TITLE; Autologous Bone Marrow Transplantation for Acute Leukemia 
Page 4 
other costs are considered standard charges Included in the bone marrow 
transplant procedure. Unfortunately, some insurance companies may refuse 
payment for all medical costs Incurred while a patient is involved witha 
research study. This will need to be discussed this with my insurance 
company, to assure payment for the bone marrow transplant. I realize that 
there could be some unforeseen costs that arise as a result of this 
research and they may not be covered by my insurance. In this event I will 
be responsible for those costs. 
9. Any information collected in this study will bo kept in strictest 
confidence. I understand that the results of this study will be published 
in a medical Journal but my name will not be published. The Food and Drug 
Administration, National Institutes of Health, or Genetic Therapy Inc. may 
review my records at any time if there is sufficient need for such action. 
A record of my progress will be sent to Dr, Ken Cornetta, the researcher 
in charge. He may also review my medical records. Histopathological 
materials used to establish my diagnosis may be sent to a central pathology 
office for review. 
10. I know that my doctors will be interested in my welfare even after I have 
completed the research study. Therefore, I will periodically be contacted 
to check on my health status. 
11. I understand that my doctor will tell me about any early results of this 
study which could influence my wish to continue to take part in the study. 
I know that I may call Dr, Cornetta at (317)274-3589 during the day with 
any questions or concerns I might have regarding my disease and treatment. 
After 5:00 p.m., I may call the bone marrow transplant physician on call 
at (317)274-0436 . 
12. I have read all of the above, asked questions, received answers concerning 
areas I did not understand and give my consent to participate in the study 
described above. My signature Indicates that I have received a copy of 
the consent form. 
Patient 
Date 
Principal Investigator 
Witness 
[506] 
Recombinant DNA Research, Volume 15 
