MEDICAL RECORD CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY Continuation; tj;, 
° AdUH Palient or ° Parert, for Minor Patient page pages 1 | I'i 
STUDYNLT.eST 
OTHER PERTINENT INFORMATION 
1. Confidentiality. When resuHs of a study such as this are reported in medical journals or at meetings, the 
identification 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 Dmg 
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 lorig-tenm medical care or financial compensation for such injuries, except as may 
be provided through whatever remedies are normally available under law. 
3. Payments. It you are a patient, you are not 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 prlr>clpal 
investigator, Robert Walker. MD . or these other staff members also involved in this study: 
Richard T. Davev. Jr..MD : Michael Polis. MD ; Judith Fatc^. MD 
Piikirn 10 Room 11C103 ^ Telephooe: (301) 496-7196 j 
National Institutes of Health 
Bethesda, Maryland 20892 j I 
5. Consent Document. It is suggested that you retain a copy of this document for your later reference and personal ' I 
records. . i 
COMPLETE APPROPRIATE ITEM BELOW. A or B: 
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, Mirior's Assent, if applicable.) 
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. 
Signature of Adult Patient & Date Signed Signature ot Parent(s) & Date Signed 
(if other than parent, spedfy relationship) 
Signature of Investigator & Date Signed Signature of Witness & Date Signed 
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Recombinant DNA Research, Volume 19 
