MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
* Adult Patient or * Parent, for Minor Patient 
STUDY NUMBER: 
.Continuation: Page. 
of 
.Pages 
OTHER PERTINENT INFORMATION 
Confidentiality. When results of a study as this are reported in medical journals or at meetings, the identification of 
those taking part is withheld. Medical records of Clinical Center patients are maintained according to current legal 
requirements, and are 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 
Policy Regarding Research-Related Injuries. The Clinical Center will provide short-term medical care for any 
physical injury resulting from your participating 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 whatever remedies are normally available under law. 
Payments. If you are a patient, you are not paid for taking part in NIH studies. Exceptions for volunteers will be 
guided by Clinical Center policies. 
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 injury, you should contact the principal 
investigator , or these other staff members also involved in this study: 
Building , Room . Telephone (301) . 
National Institutes of Health; Bethesda, Maryland 20892 
Consent Document. It is suggested that you retain a copy of this document for your later reference and personal 
records. 
COMPLETE APPROPRIATE ITEM BELOW, A OR B; 
A. Adult Patient’s Consent 
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. 
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 give permission for my child to 
take part in this study. (Attach NIH 2514-2, Minor’s 
Assent, if applicable). 
Signature and Date Signed 
Signature of Parent and Date Signed 
Relationship if other than Parent 
Signature of Witness & Date 
Signature of Witness and Date 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL 
RESEARCH STUDY 
• Adult Patient or ‘Parent, for Minor Patient 
Recombinant DNA Research, Volume 16 
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