MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
® AdUK Patiert or ° Parert, for Minor Patient 
Contirxjation: 
page 5 o( 5^ pages 
I STUOYNLTvefffe 
! OTHER PERTINENT INFORMATION 
I 1. Confidentiality. When results of a study such as this are reported in medical journals or al meetings, the 
identification of those taking part is withheld. Medical records of National Institutes of Health or Clinical Center patients are 
I maintained according to current legal requirements, and are made available for review, as required by the Food and Drug 
j 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 resultirrg from your partidpation in research here. Neither the National Institutes of Health, Clinical Center, 
!' nor the Federal government will provide fong-tenm medical care or finar>cial compensation for such injuries, except as may 
1 be provided through whatever reruedies are rtormally available urxier law. 
I 3. Payments. If you are a patient, you are rrot paid for taking part in National Institutes of Health studies. Exceptions for 
volunteers will be guided by National Institutes of Health or Clinical Center policies. 
I 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 
investigalor. Robert Walker. MD , or these other staff members also involved in this study; 
j R'dmt T. Davev. Jr.. MD ; Michael Pois. MD ^ ; Judth Falbcxi MD 
I Buidhg 10 • .Room 11C1Q3 Telephone; (301) 496-7196 
j National Institutes of Health 
j Bethesda, Marylarfo 20892 
I 5. Consent Document. It is suggested that you retain a copy of this document for your later reference and personal 
j records. 
COMPLETE APPROPRIATE ITEM BELOW, A or B; 
A. Adult Patient’s Consent. 
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. 
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. 
(Attach NIH 2514-2, Mirior's Assent, if applicable.) 
Signature of Adult Patient & Date Signed 
Signature ot Parent(s) & Date Signed 
(if other than parent, specify relationship) 
of Investigator & Date Signed 
Signature of Witness & Date Signed 
Recombinant DNA Research, Volume 19 
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