copy of this consent form has been given to the subject 
Investigator’s Signature /Date 
Subject’s Statement 
I agree to this study and to the conditions outlined in the Basic Oncology Consent Form which I have read 
and signed. I have had an opportunity to ask questions of the physicians, including questions about risks, 
benefits and alternatives to treatment These questions have been answered to my satisfaction. I 
understand future questions I may have about the research will be answered by one of the investigators 
listed above and that any questions I have about my rights as a research subject will be answered by the 
person identified above. No promises or guarantees have been made regarding the anticipated outcome 
of any tests or procedures. I am aware that I and/or my insurance carrier is responsible for the costs 
incurred in the therapy provided, including adverse effects. I understand that rhIL-3 will be given to me 
free of charge. I give permission for my medical records to be available to physicians and personnel for 
this study at the University of Washington and the Fred Hutchinson Cancer Research Center, as well as 
the Food and Drug Administration, the Sandoz Corporation, Immunex Corporation and the National 
Institutes of Health. I acknowledge that I will receive a signed copy of this consent form. 
Patient 
/Date 
Witness 
/Date 
Parent/legal guardian /Date Other parent/legal guardian /Date 
[for patients <18 years old] [if reasonably available] 
#531 2/28/91 
Copies to: Patient 
Medical Records 
Research file 
Recombinant DNA Research, Volume 16 
[341] 
