1EDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• Adult Patient or • Parent, for Minor Patient 
continuation: 
page — Z_of Lpag^ 
STUDY NUMBER;. 
OTHER PERTINENT INFORMATION 
1 . 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 legs 
requirements, and are made available for review, as required by the Food and Drug Administration or other authorizec 
users, only under the guidelines established by the Federal Privacy Act. 
2. Policy Regarding Research-Related Injuries. The Clinical Center will provide short-term medical care for any physic^ 
injury resulting from your participation in research here. Neither the Clinical Center nor the Federal gove.’-nme.nTwil 
provide long-term medical care or financial compensation for such injuries, except as may be provided through whatevel 
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 bt1 
guided by Clinical Center policies. - ~ 
4. Problems or Questions. Should any problem or question arise with regard to this study, with regard to your right[ 
as a participant in clinical research, or with regard to any research-related injury, you should contact the principcj 
investigator, , or these other staff members also involved in this stud>| 
., Room. 
.. Telephone: (301). 
Building 
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 persons] 
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 o( Aauit Patient i Oate Signea 
B. Parent’s Permission for Minor Patient. 
I have read the explanation about this study ar| 
have been given the opportunity to discuss it arj 
to ask questions. I hereby give permission for rr] 
child to take part in this study. 
(Attach NIH 2514-2, Minor’s Assent, if applicable 
signature of Parent(s) & Date Signed 
(if ot.her tnan parent, specify relationsfiipj 
Signature of Investigator & Oate Signed 
PATIENT IDENTIFICATION 
[ 304 ] 
Signature of Witness & Date Signed 
CONSENT TO PARTICIPATE IN A CLINICAL 
RESEARCH STUDY 
• Adult Patient or • Parent, for Minor Patient 
NIH-25ia-i (10-84) ■ PA 09-25-C 
Recombinant DNA Research. Volume 14 
