MEDICAL 
RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate in A Clinical 
Research Study 
STUDY NUMBER: 
CONTINUATION: page of page: 
3. Because the virus may be transmitted in several ways, it is important that you inform 
sexual and/or needle- sharing partner(s) that any, or all, of them may have been exposed to the 
HIV virus and encourage them to be tested. If you request it staff at the Clinical Center will 
assist you in notifying your partners) and arrange counseling for them through and HIV 
counselor. 
4. The results of your HIV test and/or documentation of the diagnosis of AIDS will become a 
part of your Clinical Center medical record and, as such, will be protected from unauthorized 
disclosure by the Federal Privacy Act of 1974. In general, access to your medical record will be 
restricted to those health care professionals directly involved in your care or in the conduct of 
ongoing biomedical research, and information is not usually released to other third parties 
without your permission or that of your designated representative. However, there are some 
particular routine uses of such information of which you should be aware. 
a. If you are unwilling or unable to notify your partner(s), the Clinical Center is responsible 
for attempting to contact and inform them of their possible exposure to the virus. Reasonable 
attempts will be made to protect your identity including withholding your name when notifying 
any paitner(s) of their possible exposure. Some notification or counseling of current and/or 
ongoing partners may be carried out through arrangements with, or referral to, local public health 
agencies. 
b. A summary of your care at the Clinical Center will be sent to the physician who referred 
you here for treatment. 
c. The Clinical Center may report certain communicable diseases, including AIDS and 
symptomatic HTV infection, to appropriate State and Federal government agencies. 
If you have any questions regarding the HIV testing or the information provided above, you are 
encouraged to discuss them with your physician and/or a Clinical Center HIV counselor 
(496-2381). 
The high doses of drugs in the chemotherapy regimen you will receive (see below) will cause 
prolonged suppression of your blood counts and so must be given in conjunction with a bone 
marrow transplant to help your blood counts return to normal. Therefore, bone marrow must be 
obtained from your body and stored prior to the high dose chemotherapy. The bone marrow is 
liquid and is removed with needles from the front and back of the pelvic bone and, if necessary, 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-251 4-1 (10-84) 
NIH-251 4-2 (10-84) P.A.: 09-25-0099 
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Recombinant DNA Research, Volume 16 
