I .I'ttKUurrtic-iH.ft U.I*UUM. KOUWU1 blUUT • COntrrif.vT^ - 
- L_— — ^ I • Adult Patient . or • Parent, for Minor Patient • [ page J 2 of page 
STUDY NUMBER: , ' 
OTHER PERTINENT INFORMATION 
1. Confidentiality . When results of a study such as this are reported in medical ionm^ 
or at meetings, the identification of those taking part is withheld. Medical record nf 
Clinical Center patients are maintained according to current legal requirements and ° r 
made available for review, as required by the Food and Drug Administration or other ^ 
authorized users, only under the guidelines established by the Federal Privacy Act 
I 
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 Clinical Center nor the Federal government will provide long-term medical 
care or financial compensation for such injuries, except as may be provided through 
j whatever remedies are normally available under law. 
3. Payments . You will not be paid for taking part in this study. The Clinical Center 
does not charge for medications, doctors* care or hospitalization. Exceptions for 
Normal Volunteers are guided by Clinical Center and Normal Volunteer Office policies. 
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 inj'uiy, you should contact the principal investigator, 
Cynthia E. Dunbar/ M.D. , or these other staff members also involved in this 
Study , Arthur W. Nienhuis, M.D., Donna Viriina, R.N. ' ; 
Building 10 , Room 7C103 I Te 1 ephone: ( 301 ) 496^so^3 ~ 
National Institutes of Health 
Bethesda, Maryland 20205 
COMPLETE APPR0PRIA1 
E ITEM BELOW. A or B: 
.. 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 consent 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 give permission for my child to 
take part in this study. 
(Attach NIH 2514-2, Minor's Assent, if 
appl icable. ) 
v^S.ignature of Adult Patient & Date Signed 
Signature of Parent(s) & Date Signed 
(if other than parent, specify relationship) 
Signature of Investigator & Oate Signed 
Signature of Witness & Date Signed 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• Adult Patient or • Parent, for Minor Patient 
NIK-2514— t (6-82) 
P.A.: 09-25-0099 
Recombinant DNA Research, Volume 16 
[81] 
