MEDICAL 
RECORD 
CONTINUATION SHEET for either: 
NIH 25M-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 _JL_ of _6_ page: 
Participation in this study is entirely voluntary. You may choose to participate or may . 
withdraw from the gene transfer study at any time up to the time of infusion of the bone marrow 
and circulating blood cells. Enough bone marrow and peripheral blood cells have been harvested 
to be able to proceed with the transplantation even without the cells that are treated with the 
neo^ - gene. If you withdraw your consent, the gene-marked cells will not be infused. In the 
event that you do withdraw your consent after harvest, but do go ahead with transplantation, the 
course of your disease will be followed on a regular basis at the NIH. You are encouraged to ask 
any questions that you may have and to take as much time as you need to make your decision. 
The costs of hospitalization, treatment, and laboratory procedures related to the bone marrow 
transplantation that are provided at NIH are paid for by NIH. It is important to understand that 
NIH cannot pay for tests or medical care you receive outside of NIH. 
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 
