Subject’s Statement 
I agree to this study. I have had an opportunity to ask questions of the physicians, including questions 
about risks, benefits and alternatives to treatment. I have also had the opportunity to ask questions 
about the study, my participation and the need for access to my medical records. They have been 
answered to my satisfaction. I understand future questions I may have about the research will be 
answered by one of the investigators listed above and that any questions I have about my rights as a 
research subject will be answered by the person identified above. No promises or guarantees have been 
made regarding the anticipated outcome of any tests or procedures. I am aware that I will not be 
charged nor will I be paid for my participation in this study although I will be charged for the medical 
and hospital care I require independent of this study just as though I were not part of this study. 
I give permission for my medical records to be available to physicians and personnel for this study at 
the University of Washington and the Fred Hutchinson Cancer Research Center, the National Institutes 
of Health, and the Food and Drug Administration. I acknowledge that I will receive a signed copy of 
this consent form. 
Patient 
/Date 
Witness 
/Date 
Parent/legal guardian 
[for patients < 18 years old] 
/Date 
Other parent/legal guardian 
[if reasonably available] 
/Date 
#838.0 - 09/28/93 
Copies to: Patient, Medical Records, Research file 
Signed Consent MUST be sent to Data Management - Eklind 206 
i] 
if 
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Recombinant DNA Research, Volume 18 
