Attachment IV - Page 1 
DEPARTMENT OF.-H6ALTH AND HUMAN SERVICES 
PUBLIC HEALTH SERVICE 
FOOD ANO DRUG ADMINISTRATION 
Form approved; OMB No. 09 1 (F00 1 3 
Expiration Date: December 31, 1984. 
STATEMENT OF INVESTIGATOR 
» 
Note: No drug may be shipped or study initiated unless 
a completed statement has been received 
(21 Ch'R 312. l(a)(12)). 
i TO: SUPPLIER OF ORUG (Name, address, and Zip Code) 
NAME OF INVESTIGATOR (Print or Type) 
OATE 
NAME OF ORUG 
Dear Sir: 
The undersigned. 
submits this statement as required by section 505(i) of the Federal Food, Drug, and Cosmetic Act and §3 1 2. 1 of Title 21 of the Code of 
Federal Regulations as a condition for receiving and conducting clinical investigations with a new drug limited by Federal (or United States) 
law to investigational use. 
1. THE FOLLOWING IS A STATEMENT OF MY EDUCATION ANO EXPERIENCE: 
*. COLLEGES. UNIVERSITIES. AND MEDICAL OR OTHER PROFESSIONAL SCHOOLS ATTENOED. WITH OATES OF ATTENDANCE. DEGREES. 
AND DATES OEGREES WERE AWARDED 
b. POSTGRADUATE MEDICAL OR OTHER PROFESSIONAL TRAINING. GIVE OATES. NAMES OF INSTITUTIONS. AND NATURE OF TRAINING. 
c. TEACHING OR RESEARCH EXPERIENCE. GIVE DATES. INSTITUTIONS. ANO 
BRIEF DESCRIPTION OF EXPERIENCE. 
<S. EXPERIENCE IN MEDICAL PRACTICE OR OTHER PROFESSIONAL EXPERIENCE. GIVE OATES. INSTITUTIONAL AFFILIATIONS. NATURE 
OF PRACTICE. OR OTHER PROFESSIONAL EXPERIENCE. 
•. REPRESENTATIVE LIST OF PERTINENT MEDICAL OR OTHER SCIENTIFIC PUBLICATIONS. GIVE TITLES OF ARTICLES, NAME OF 
PUBLICATIONS AND VOLUME. PAGE NUMBER, AND DATE. 
IF THIS INFORMATION HAS PREVIOUSLY BEEN SUBMITTED TO THE SPONSOR, IT MAV BE REFERRED TO AND ANY ADDITIONS 
MAOE TO BRING IT UP-TO-DATE. 
PREVIOUS EDITIONS ARE OBSOLETE. 
[ 589 ] 
FORM FOA 1573 (10/83) 
