CONFIDENTIALITY 
I understand that any information about me will be kept in locked files 
with limited access and not distributed without my permission. 
I understand that any information about me or my treatment will be treated 
in the same confidential manner as other hospital medical records. I consent to 
publication of any information for scientific purposes so long as my identity 
will not be revealed. 
RIGHT TO WITHDRAW 
I understand that I may refuse to participate in this study or withdraw any 
time and that my decision will not adversely affect my care at this 
hospital/institution or cause a loss of benefits to which I might otherwise be 
entitled. I also understand that I may be withdrawn from the study by the 
investigators. 
VOLUNTARY CONSENT 
Dr. Barranger has explained all of this to me and has answered all 
questions I have. I also understand that any future questions I have about this 
research will be answered by Dr. Barranger who I may call at 412/624-4623. Any 
questions I have about my rights as a research subject will be answered by the 
Office of the Senior Vice President for Health Sciences at the University of 
Pittsburgh. By signing this form, I agree to participate in this study. 
Patient's Signature* 
Witness 
Date and Time 
* The patient is unable to consent because: 
I, therefore, consent to participation for the patient. 
Relationship to Patient Signature of Patient's Representative 
Witness Date 
Recombinant DNA Research, Volume 17 
[779] 
