INVESTIGATOR’S STATEMENT 
I have provided an explanation of the above research program. The subject was given an opportunity to 
discuss the procedures, including possible alternatives, and to ask any additional questions. A signed 
copy of this consent form has been given to the subject. 
Investigator’s Signature /Date 
SUBJECTS 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. I have also have the opportunity to ask questions about 
the study, my participation and the need for access to my medical records. They 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. Any financial questions or questions I have about my rights as a research 
subject will be answered by the persons 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 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, the National Institutes of Health, the Food and Drug Administration, and 
Amgen (drug company making G-CSF). 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] 
#753.0A -06/17/92 
Copies to: Patient, Medical Records, Research file 
[376] • 
Recombinant DNA Research, Volume 16 
