MEDICAL RECORD 
DURABLE POWER OF ATTORNEY (DPA) 
Power of Attorney: 
Do not fill out this form unless you wish to designate someone to consent to your 
participation' in research and routine clinical care in the event you become incompetent to 
provide your own consent. 
Full Address 
. . . (Name of Patient) 
City' 
State 
Zip: ; 
(Name of individual receiving durable power of attorney) 
Full Address 
. . .... 
City 1 ' ''• • 
• • State - - Zip v ‘ ' ’ 
1 (the principal) hereby 
authorize 
(my representative) 
in the event that i 
1 become disabled or incompetent, to exercise Power of Attorney over my 
; person for the sole purpose of providing informed consent on my behalf for my participation 
in research protocols and routine clinical care. I understand that, unless revoked by me, the 
appointee shall hold the Power of Attorney for this purpose until completion of my 
participation in research at the National Institutes of Health. 
Executed this day of _ , 19 . 
Signature of patient 
The signature of this witness attests that the person who signed as “patient” is the subject 
of research who appointed the representative named in this document. 
Signature of witness 
Date 
Patient Identification 
Durable Power of Attorney (DPA) 
NIH-200 (9-S7) 
P.A.: 09-25-CC9? 
Recombinant DNA Research, Volume 15 
(File as CorresDondencel 
[851] 
