MEDICAL RECORD 
CONSENT-TO PARTICIPATE IN. A CLINICAL RESEARCH STUDY •" | : continuation: T — 
• Adult Patient or > Parent, for Minor Patient • page 14 o f 14 p age: 
STUDY NUMBER: 
OTHER PERTINENT INFORMATION 
Confidentiality . When results of a study such 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 pood and Drug Administration or other 
authorized users, only under the guidelines established by the Federal Privacy Act. 
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 
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 injury, you should contact the principal investigator, 
Cynthia E. Dunbar, M.p. , or these other staff members also involved in this 
S tudy , Arthur W. Nienhuis/ M.P./ Donna Vininq/ R.N. 
Build ing 10 , Room 7C103 Telephone: (301) 496-5093 
National Institutes of Health 
‘ Bethesda, Maryland 20205 
r 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. ) 
Sigryrture.of Adult Patient & Date Signed 
Signature of Parent(s) & Date Signed 
(if other than parent, specify relationship) 
Signature of Investigator & Date Signed Signature of Witness & Date Signed 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• Adult Patient or • Parent, for Minor Patient 
Recombinant DNA Research, Volume 16 
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