MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• Adult Patient or • Parent, for Minor Patient 
continuation; 
page_2 — of? — .pages 
STUDY NUMBER: 
1 . 
2 . 
3. 
. ! 4. 
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 Food and Drug Administration or other authorized 
users, only under the guidelines established by the Federal Privacy Act. 
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. 
Payments. If you are a patient, you are not paid for taking part in NIH studies. Exceptions for volunteers will be 
guided by Clinical Center policies. . 
Problems or Questions. Should any problem or question arise with regard to this study, with regard to your rights 
as a participant it] clinical research^cwith^egard to any research-related injury, you should contact the principal 
investigate , rn.u. ^ these other staff members also involved in this study; 
Building |o 
., Room 
.. Telephone: (301) A96-416A 
National Institutes of Health 
Bethesda, Maryland 20205 
5. 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.) 
Signature ol Parents) i Date Sigrted 
(i< otfter tfian parent, apeofy reiauonahip) 
Sigrvaiure ot Investigator & Date Signed 
Signature ol Waness i, Date Signed 
Recombinant DNA Research, Volume 14 
[ 21 ] 
• Adult Patient or • Parent, tor Minor rauem 
WH-2S14-1 (1(N44) ' 09-25-009^ 
