CERTIFICATION OF PATIENT CONSENT 
Project Title: Gene Therapy for the Treatment of Malignant Brain Tumors with In Vivo Tumor 
Transduction with the Herpes Simplex Thymidine Kinase Gene/Ganciclovir System 
Investigator: John C. VanGilder, M.D. 
i# hereby certify that I have been told by 
(subject's name) 
of the Department of Neurosurgery about research 
(investigator) 
of malignant brain tumors and its purpose. I have been told about the procedures to be followed, 
which of them are experimental, and how much time is involved. I understand the possible risks 
and discomforts I may experience and the possible benefits to me and to others from the research. 
I have also been told the extent to which any records which may identify me will be kept 
confidential. 
A written summary of what I have been told is attached. I have been given adequate 
opportunity to read it. 
I understand that I have the right to ask questions at any time and that I should contact 
John C. VanGilder, M.D. at (319) 356*2772 for answers about the research and my rights. 
I understand that in the event of physical injury resulting directly from the research 
procedures, no compensation will be available in the absence of negligence by a state employee. 
However, medical treatment is available at The University of Iowa Hospitals and Clinics, but I will be 
responsible for making arrangements for payment of the expenses of such treatment. Further 
information may be obtained from Dorothy M. Maher, Division of Sponsored Programs, Office of the 
Vice President for Research, (319) 335-2123. 
Recombinant DNA Research. Volume 17 
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