MEDICAL 
RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Conaent to Participate in A Clinical Research Study 
NIH 251 4-2, Minor Patient’s Assent to Participate in A Clinical 
Research Study 
STUDY NUMBER Continuation: page 6 of pages 
OTHER PERTINENT INFORMATION 
Confidentiality. When results of a study as this are reported in medical journals or at meetings, the identification 
of those taking part is withheld. Medical records of National Institutes of Health or 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 AcL 
Policy Regarding Research-Related Injuries. The Clinical Center will provide short-term medical care for 
any physical injury resulting from your participating in research here. Neither the National Institutes of Health, 
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 National Institute of Health studies. 
Exceptions for volunteers will be guided by the National Institutes of Health or 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 in clinical research, or with regard to any research-related injury, you should contact the 
principal investigator , or these other staff members also involved in 
this study: ; ; : 
Building , Room . Telephone (301) . 
National Institutes of Health; Bethesda, Maryland 20892 
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 and Date Signed 
Signature of Witness & Date 
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 of Parent and Date Signed 
Relationship if other than Parent 
Signature of Witness & Date 
PATIENT IDENTIFICATION I CONTINUATION SHEET FOR EITHER: 
I NIH-251 4-1 (9-91) 
I NIH-251 4-2 (9-91) P. A. :09-25-0099 
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Recombinant DNA Research, Volume 18 
