STATEMENT OF UNDERSTANDING 
The benefits of this experimental treatment are difficult to predict. From experience at 
other childhood cancer centers, we expect that 1 of every 2 children treated this way will 
remain free of leukemia for at least 2 years after the completion of high-dose chemotherapy 
and bone marrow transfusion. 
Participation in the study is strictly voluntary. If you/your child does not wish to volunteer, 
other options will be discussed and made available. Should any problems arise, one of the 
doctors will make you/your child aware of these developments and discuss plans of action. 
1. I have read the above treatment and voluntarily agree to the participation of 
myself/my child ___ in this study/ treatment. 
2. I have had adequate opportunity to discuss with Dr. 
name of investigator 
caring for me/my child all the purposes and hazards related 
to this study/treatment. 
3. I have been told of alternative courses of action in my/my child's situation. 
4. I understand that the study/treatment proposed may result in risks that are currently 
unforeseeable. 
5. I understand that I may withdraw myself/my child from this study/treatment at any 
time without jeopardy to further treatment. 
6. I understand that without marrow transfusion, chances for surviving chemotherapy 
with busulfan and cytoxan are very poor. 
7. I understand that financial compensation is not provided for participation in this 
study/treatment. 
8. I understand that in the event of non-negligent physical injury to myself/my child 
from this study/treatment, financial compensation is not available but medical 
treatment necessary will be provided at no direct cost. 
9. I understand that information obtained will be kept confidential but that supervised 
review by approved medical representatives of outside institutions or agencies may 
occur. In particular, the chart may be reviewed by an agent of the Food and Drug 
Administration, the National Cancer Institute or their agent, and the Clinical Trials 
Monitoring Service. No information will be released to the press without my/my 
child's permission. 
Recombinant DNA Research, Volume 17 
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