NOT VALID WITHOUT INSTITUTIONAL REVIEW BOARD APPROVAL 
Page 5 of 5 ST. ELIZABETH'S MEDICAL CENTER 
INFORMED CONSENT 
FOR 
EXPERIMENTAL PROCEDURES 
IRB Approval 
Stamp 
I fully understand the nature and scope of this research activity and have been given sufficient 
opportunity to consider my participation. I have been given the opportunity to ask questions 
which have been answered to my satisfaction. 
I voluntarily sign this form with a full understanding of the nature of this activity, including but 
in no way limited to the potential results. 
I hereby consent to my medical records relating to this research being made available to state and 
federal agencies which regulate medical research, including this experiment. 
Upon request, I or my representative will receive a copy of this consent form. 
I understand that the Research/Human Subjects Committee of St. Elizabeth's Medical Center has 
approved the solicitation of subjects to participate in this research. 
Witness Participant/Parent/Guardian 
I hereby certify that on this date a copy of this Consent Form has been provided to the above 
named Participant/Parent/Guardian 
PRINCIPAL INVESTIGATOR’S STATEMENT: 
I have fully explained to 
Participant 
the nature and purpose of the above described procedure and the risks that are involved in its 
performance. I have answered all questions to the best of my ability. 
Any new unforeseen information relevant to the patient which may develop during the course of 
the research will be provided to the participant and the Research/Human Subjects Committee. 
Date 
Date 
Principal Investigator or Representative 
Witness 
Principal Investigator or Representative 
Date 
Witness 
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Recombinant DNA Research, Volume 20 
