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 
Other parent/legal guardian /Date 
[if reasonably available] 
#753.0C - 06/17/92 
Copies to: Patient, Medical Records, Research file 
Parent/legal guardian /Date 
[for patients < 18 years old] 
[380] 
Recombinant DNA Research, Volume 16 
