MEDICAL RECORD 
CONSENT TO PARTICIPATE IN. A CLINICAL RESEARCH STUDY 
• Adult Patient or • Parent, for Minor Patient 
continuation: 
page ^ of ^ pages 
STUDY NUM8ER: 
OTHER PERTINENT INFORMATION 
1 . Confidentiality. When results of a study such as this are reported in medical journals or at meetings, the identifica- 
tion of those taking part is withheld. Medical records of National Institutes of Health or Clinical Center patients 
are maintained according to current legal requirements, and are made available for review, as required by the Food 
and Drug Administration or other authorized users, only under the guidelines established by the Federal Privacy Act. 
2. Policy Regarding Research-Related Injuries. The Clinical Center will provide short-term medical care for any physical 
injury resulting from your participation in research here. Neither the National Institutes of Health, Clinical Center 
nor the Federal government will provide long-term medical care or financial compensation for such injuries, ex- 
cept as may be provided through whatever remedies are normally available under law. 
3. Payments. If you are a patient, you are not paid for taking part in National Institute of Health studies. Exceptions 
for volunteers will be guided by the National Institutes of Health or Clinical Center policies. 
4. Problems or Questions. Should any problem or question arise with regard to this study, with regard to your rights 
as a participant in clinical research, or with regard to any research-related injury, you should contact the principal 
investigator, Cynthia E. Dunbar / M.D. or these other staff members also involved in this study: 
Donna Vininq, M.D. ; Norman Barton, M.D. , Ph.D.: Michelle Cottier-Fox, M.D j 
_1£L 
Room 7C1Q3 
Telephone: (301) 496-5093 
Building . 
National Institutes of Health 
Bethesda, Maryland 20205 
5. Consent Document. It is suggested that you retain a copy of this document for your later reference and personal 
records. 
COMPLETE APPROPRIATE ITEM BELOW, A or B: 
A. Adult Patient’s Consent. 
I have read the explanation about this study and have 
been given the opportunity to discuss it and to ask 
questions. I hereby consent to take part in this study. 
B. Parent’s Permission for Minor Patient. 
I have read the explanation about this study and have 
been given the opportunity to discuss it and to ask 
questions. I hereby give permission for my child to 
take part in this study. 
(Attach NIH 2514-2, Minor’s Assent, if applicable.) 
Signature of Parent(s) & Date Signed 
(If Other Than Parent, Specify Relationship) 
Signature of Investigator & Oate Signed 
Signature of Witness L Oate Signed 
PATIENT IDENTIFICATION 
Recombinant DNA Research, Vbhime 1' 
CONSENT TO PARTICIPATE IN A CLINICAL 
RESEARCH STUDY (Continuation Sheet) 
• Adult Patient or • Parent, for Minor Patient 
NIH-2514-1 (9-SI) 
P A 09-25-0099 
-f829] 
Pit* m Section 4 Protocot Consent 
