disease, outpatient visits, hospitalization, routine blood samples and other tests to evaluate the course of my tumor 
prior to and following therapy. The cost of the experimental therapy will be bom by the University of Pittsburgh. 
CONFIDENTIALITY : A record of my progress while on the study will be kept in a confidential form in the 
Pittsburgh Cancer Institute. During reviews of this data, which are required by the Food and Drug Administration as 
well as the National Cancer Institute, access will be provided to my medical records that might reveal my identity. 
In addition, the sponsor of this protocol will have access to my medical records that contain information regarding 
my identity. My medical records may be reviewed by qualified members of the Pittsburgh Cancer Institute. Copies 
of information contained in my record, such as laboratory test results, will be made for my research record. 
However, no information by which I can be identified will be released or published. 
My records, like hospital records, may be subpoenaed by court order. I consent to publication of the results of this 
study, so long as I am not identifiable by name in such publications. 
RIGHT TO WITHDRAW : Participation in this study is voluntary. I am firee to withdraw my consent to participate 
in this treatment program at any time without prejudice to my subsequent care. The doctors have urged me not to 
withdraw so that I can be safely observed, especially during the period immediately after the immunizations. I realize 
that I should receive careful medical follow-up of the immunization sites. If I withdraw from the study I should have 
other physicians involved in my care notified of this treatment Refusing to participate will involve no penalty or 
loss of benefits. I am free to seek care from a physician of my choice at any time. Life-long follow up will be 
required and I will inform the investigators of my current address and phone number in the event that I move. 
COMPENSATION FOR ILLNESS OR INJURY : I understand that in the event of physical injury or illness 
resulting from this research procedure no monetary compensation will be made or provision for long term medical 
care. Any immediate emergency medical treatment including hospitalization that may be necessary will be provided. 
VOLUNTARY CONSENT : I certify that I have read the proceeding or that it has been read to me, and I understand 
its contents. Any questions I have pertaining to the research have been, and will continue to be answered by the 
investigators listed on the front sheet of the consent form. Any questions I have concerning my rights as a research 
subject will be answered by the Office of the Senior Vice Chancellor, Health Sciences. A copy of this consent form 
will be given to me. My signature below means that I freely agree to participate in this experimental study. 
Date Patient's Signature 
I certify that I have explained to the above individual the nature and purpose, the potential benefits, and possible 
risks associated with participating in this research study, have answered any questions that have been raised, and have 
witnessed the above signature. 
Date 
Investigator’s Signature 
Witness's Signature 
3/28/94 
Recombinant DNA Research, Volume 19 
Patient's Initials 
[6691 
