MEDICAL 
RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate In A Clinical Research Study 
NIH 2514-2, Minor Patient's Assent to Participate In A Clinical 
Research Study 
STUDY NUMBER CONTINUATION: page &of pages. 
platelet count drop significantly. Discontinuation of the drug results in normalization of the white 
blood cell and platelet numbers. Cytovene® may cause permanent or temporary infertility and may 
be associated with birth defects. Therefore, women of childbearing age should use effective 
contraception during Cytovene® and men should use contraception during and for at least 90 days 
following Cytovene® therapy. Pregnant women are not eligible for this protocol. Cytovene® can 
cause cancer in animals. There is no information available to estimate the risk of this in humans. 
Durable Power of Attorney 
You have an illness that at some point may impair your ability to think clearly and to make 
decisions. A Durable Power of Attorney is a process by which you appoint someone to make 
decisions about your medical care at the Clinical Center should you become, and only if you 
become, unable to make these decisions yourself. Such people might include a husband, wife, 
other family member or close friend. It is important that this person know your moral, religious and/or 
personal preferences in research and medical care. The Clinical Center Durable Power of Attorney 
form has no legal standing outside the NIH but helps us give you good medical care and assures 
that your preferences in research and medical care are respected, if you should be unable to give 
informed consent. 
A tentative agreement to an autopsy. 
In case of death during or after your participation in this research study, we ask you for a tentative 
agreement to an autopsy. This will provide us with an opportunity to learn more about the effect of 
our treatment of your tumor. 
I 
i 
PATIENT 
IDENTIFICATION 
CONTINUATION SHEET for either 
NIH-2514-1 (10-84) 
Recombinant DNA Research, Volume 15 
[845] 
