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: 
consent is on file with the Clinical Research Committee of the National Cancer Institute and a 
copy is available to you when you sign it and at any future time. Your participation in this study 
is entirely voluntary. However, if you decide to withdraw from this study during the period of 
low white count and platelets following transplant (approximately 6 weeks), you will be at great 
risk of medical complications and death. Your refusal to participate in this study will involve no 
loss of benefits to which you are entitled, nor will your refusal in any way penalize your care. 
Confidentiality will be maintained during this study. When results of the study are discussed 
in medical meetings or journals, the identification of those taking part is withheld Medical 
records or patients are held in strict confidence according to law but they may be made available 
for review, as required by the U.S. Food and Drug Administration, under the guidelines 
established by the Federal Privacy Act The National Cancer Institute, the FDA, or the relevant 
drug companies may review your records. Upon completion of this study, you will be given the 
option of participating in additional research protocols that may be appropriate for you. It is 
important to stress that participating in this protocol does not constitute a promise of long term 
care here at the NIH Clinical Center. If there is no research study that is suitable for you, 
however, you will be returned to the care of your private physician, or to alternative sources 
closer to home. It is conceivable that participating in this study might make you ineligible to 
participate in certain other research protocols because the requirements for entry into these 
protocols may disallow patients who have been on certain drugs. You may decide now now to 
receive treatment in this study or you may choose at any point to study the drug and withdraw 
from the protocol; in either case, you would be returned to the care of your referring physician. 
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 
