CERTIFICATION OF SUBJECT CONSENT 
BY LEGALLY AUTHORIZED REPRESENTATIVE 
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. 
. the of 
(representative's name) (relationship or legal status) 
hereby certify that I have been told by 
of the Department of Neurosurgery about the research for 
malignant brain tumors and its purpose in which my has been 
asked to take part. 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, and 
the possible benefits relating to this research project. I have also been told about any appropriate 
alternative procedures that might be helpful to the subject. I have also been told the extent to 
which any records which may identify the subject 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 
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