MEDICAL RECORD 
CONSENTTO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• Adult Patient or • Parent, for Minor Patient 
continuation: 
page(\ of 14 
pages 
STUDY NUMBER 
OTHER PERTINENT INFORMATION 
1 . Confidentiality. When results of a study such as this are reported in medical journals or at meetings, the identification of those taking part is withheld 
Medical records of Clinical Center patients are maintained according to current legal requirements, and are made available for review, as required by the j- 
Food and Drug Administration or other authorized users, only under 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 physical injury resulting from your 
participation in research here Neitner the Clinical Center nor the Federal government will provide long-term medical care or financial compensation for 
such injuries, except as may be provided through whatever 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 be guided by Clinical Center policies. 
4. Problems or Questions Should any problem or question arise with regard to this study, with regard to your rights as a participant in clinical research, or j 
with regard to any research-related injury, you should contact the principal investigator Edward H. Oldfield, M.D. orthese 
other staff members also involved in this study; Zvi Ram, M.D« Building 10 , Room 5D37 Telephone: A96~5 728 . Bethesda, Maryland 
20892 
Between 5 pm and 8 am, weekends and holidays, contact the Neurology on-call physician on 496-4567 
5. Consent Document it is suggested that you retain a copy of this document for your later reference and personal records. 
COMPLETE APPROPRIATE ITEM BELOW, A OR B 
A. Adult Patient's Consent 
I have read the explanation about this 
study and have been given the oppor- 
tunity to discuss it and to ask questions. 
I hereby consent to take part in this study. 
Signature of Adult Patient & Date Signed 
B. Parent's Permission for Minor Patient. 
I have read the explanation about this study and 
have been given the opportunity to discuss it and 
to ask questions. I hereby give permission for my 
child to take part in this study. 
(Attach NIH 2514-2, Minor's Assent, if applicable.) 
Signature of Parent(s) & Date Signed 
(if other than parent, specify relationship) 
Signature of Investigator & Date Signed 
Signature of Witness 8 Date Signed 
PATIENT IDENTIFICATION 
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CONSENTTO PARTICIPATE IN A CLINICAL RESEARCH ‘ 
STUDY 
Recombinant DNA Research, Volume 15 
NIH 2514 1 (10 84,i 
P 4 09 25 0099 
