MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• Ac'jit ^atient or • Parent, for Minor Patient 
STUDY NUMBER: 
OTHER PERTINENT INFORMATION 
H 
paces 
continuation 
cage (o of 
1 . Confidentiality. When results of a study such as this are reported in medical journals or at meetings, the identification l! 
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. j 
2. 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 suoh injuries, except as may be provided through whatever j 
remedies are normally available under law. 
3. 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. 
4. Problems or Questions. Should any problem or question arise with regard to this study, with regard to your rights 
as a participant in clinical research, or with regard to any research-related injury, you should contact the principal 
investigator. R. Michael Rlnpsp, M.n. or these other staff members also involved in this study; 
Kenneth W. Culver. M.D. ;• ■ ; ; 
Building , Room Telephone: (301) 496-5396 
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. 
Signature of Aouit Patient & Date Signed 
Signature of Investigator & Date Signed 
PATIENT IDENTIFICATION 
[250] 
B. Parent’s Permission for Minor Patient. 
I have read the explanation about this study anc 
have been given the opportunity to discuss it and 
to ask questions. I hereby give permission for m> 
child to take part in this study. 
(Attach NIH 2514-2, Minor’s Assent, if applicable.) 
Signature of Parent(s) & Date Signed 
(if otner than parent, specify relationship) 
Signature of Witness & Date Signed 
CONSENT TO PARTICIPATE IN A CLINICAL 
RESEARCH STUDY 
• Adult Patient or • Parent, for Minor Patien;" 
Recombinant DNA Research, Volume 14 
