Investigator’s Signature 
/ Date 
Subjects’ 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 any involvement in this treatment. These questions have been answered to my 
satisfaction. I understand future questions I may have about the research will be answered by one of the 
investigators listed above and that any questions I 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 and the National Cancer Institute. I 
acknowledge that I received a signed copy of this consent form. 
Donor 
/Date 
Witness 
/ Date 
Parent/Legal Guardian /Date 
(for donors < 18 years old) 
Other Parent/Legal Guardian /Date 
(if reasonably available) 
#696D - 10/08/91 
Copies: Patient, Medical Records, Research File 
[646] 
Recombinant DNA Research, Volume 15 
