If you agree to participate in this study you are asked also to consent to have an autopsy 
performed on your body after your death. The reason for this request is that much 
information that is of potential benefit to future recipients of gene therapy can be 
learned that way. 
SIGNATURE 
Dr. has explained the purpose and risks of this study to me and answered 
all of my questions. 
If I am female, I am and will not become pregnant during this study. 
I have asked for and received all information I need to use effective methods of 
contraception and will use such methods for the duration of the study. 
I hereby grant permission for a full autopsy following my death. I also stipulate that this 
permission may not be rescinded by any relatives, next of kin, legal guardian or 
representative or holder of power of attorney. 
My blood will be used in research to be conducted by University of California personnel. 
The cells and fluids from my blood, or their derivatives, or material obtained at autopsy 
may have significant therapeutic and commercial value. I consent to such uses. I hereby 
release the University of California from any liability for such use. 
If I have other questions or research related problems I may call Dr. at 
I have received a copy of this consent document to keep and a copy of “The Experimental 
Subject's Bill of Rights." 
I have read, understand and agree with all four pages of this consent document. 
I hereby agree to participate. 
Subject's Signature 
Witness's Signature 
Date 
[404] 
Recombinant DNA Research, Volume 18 
