about your rights as a research participant, please contact Karen Hansen in the Institutional Review Office of 
the Fred Hutchinson Cancer Research Center at 206/667-4867. 
Investigator’s Statement 
I have provided an explanation of the above research program. The subject was given an opportunity to 
this consent form has been given to the subject. 
Investigator’s Signature 
/Date 
Subject’s Statement 
I agree to this study and to the conditions outlined in the Basic Oncology Consent Form which I have read 
and signed. I have had an opportunity to ask questions of the physicians, including questions about risks, 
benefits and alternatives to treatment. These questions have been answered to my satisfaction. I understand 
future questions I may have about my rights as a research subject will be answered by the person identified 
above. No promises or guarantees have been made regarding the anticipated outcome of any tests or 
procedures. I am aware that I and/or my insurance carrier is responsible for the costs incurred in the therapy 
provided, including adverse effects. I give permission for my medical records to be available to physicians 
and personnel for this study at the University of Washington and the Fred Hutchinson Cancer Research 
Center, as well as the Food and Drug Administration, Burroughs Wellcome Co., Immunex Corporation, and 
the National Institutes of Health. I understand that my medical records will be kept confidential but that 
members of the health care team will access to these results and records. I acknowledge that I will receive a 
signed copy of this consent form. 
Patient 
/Date 
Witness 
/Date 
Parent/legal guardian 
[for patients < 18 years old] 
/Date 
Other parent/legal guardian 
[if reasonably available] 
/Date 
#696A - 10/08/91 
Copies: Patient, Medical File, Research File 
[640] 
Recombinant DNA Research, Volume 15 
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