WPC=  #J&ߤ/*& [}s`a(b`,'4"W52?;- -9xP1o5SozRm}S٤C0;\r֦]xÑ^|@@GK>[[d? >W ItwMÖ1J ðG?!)Fv~;.YhЁ'_}ANh=i;(_aԋiĀ#!4UNU % 0(U:  0 e6w@>4~ mN^  1 1uW 0c 1/ 1HP LaserJet 5P,,,,,,0xhH  Z6Times New Roman RegularX($  AZ"Arial Regular1, 2, 3,Level 1Level 2Level 3Level 4Level 54#(.2Quick 1.  .0   EE[E22[9+3|xUy*.c(5hCEKQW]cioAutoList11.1.1.1.1.1.1.1.3#37=CIQYag1.a.i.(1)(a)(i)1)a)(;3$2#  0  .3  0  (EhCEKQW]cioAutoList21.1.1.1.1.1.1.1.(UhCEKQW]cioAutoList31.1.1.1.1.1.1.1. !  _wXXXX &%XX@r r CONFIDENTIALDISCLOSUREAGREEMENT  w ThisAgreementismadebyandbetweenthe InstituteionName ,havingaplaceofbusinessat address  ' Ѐ,( Institution)withDr. PIname asemployeeofInstitution,and Patient/family  membername #XX%&#&%XX h TheInstitutionhasan_NCI_Ԅsponsoredclinicalstudy, Protocolno.entitled   Ѐ(referredtointhisAgreementas Protocol);and c  [Selectone:]     [A.UseforPatientRequests]  Patientname willbeexaminingtheProtocol duetothisindividuals  D  participationinthisclinicalstudy ] .    [B.UseforrequestbyRelative]  Familymembername whowillbeexaminingtheProtocol dueto ?  theparticipationof patientsname ,the relation of familymembername ,inthisclinicalstudy. ]    TheInstituteand Patient/familymembername dd(hereinafter Patient/familymember)dddagreeas ( follows:(.  (.1  .0    TheInstitutioneshallprovideacopyoftheProtocolto thePatient/familymembersolelyforthe # purpose of reviewingtheclinicalstudyproceduresinadditiontotheinformationcontainedinthe  InformedConsentformoftheclinicalstudynamedabove.(.,ی T$T$ Ќ  (.  (. 2  .0    ThePatient/FamilymemberagreestoaccepttheProtocolandtokeeptheProtocolsecretand s confidential. TheProtocol doftheInstituted shallnotbedisclosed,revealed,orgiventoanyoneby the G Patient/familymemberexcept otherimmediatefamilymemberswhowillbeinformedbythe  Patient/FamilymemberthattheddProtocoldisdsecretandconfidential.(. 7 یxT$T$ Ќ  (.  (. 3  .0    ItisacknowledgedbytheInstitutionthatthePatient/familymembershallincurnoliabilityfor   examiningtheProtocol;however,thePatient/familymemberagreesthat theProtocolwillonly k beusedfor thepurposesdescribedabove.(. 0 ی? T$T$ Ќ  ??US.,_0  US.,??.,  ??US., 04T$T$0 4T$4T$ 4    T$ T$ 0   4.  TheUS.,??.,?Patient/Familymember??US.,sobligationsunderParagraphs2and3shallbeineffectfora p" periodof five(5)yearsoruntilcompletionoftheprotocolorsubsequentanalysesoftheProtocoldata,whicheveroccurslater US.,??., ??US.,ԀunlesstheInstitutioninformsthePatient/FamilyMember $ thattheProtocolisstillsecretandconfidential,inwhichcasetheobligationsofParagraphs2and3shallextendforanadditionaltwo(2)years.US.,??.,.??US., T$T$ L Eh(3L 3   32Eh  5  .3  0    TheobligationtokeeptheProtocolUS.,??.,=??US.,Ԁinformationsecretandconfidentialshallnotapplyto "h!( Protocolinformationwhichispublished,alreadyknowntoUS.,??.,thePatient/Familymember??US.,,receivedbytheUS.,??.,^Patient/Familymember??US.,Ԁfromanothersourcenotobligatedtokeepthisinformation $#* secret,orinformationrequiredtobedisclosedbylaw.3݌ T$T$ Ќ  0   US.,??., T$T$ L Uh((L 3   3!2Uh  6  .3  0    IfanyprovisionofthisAgreementisfoundtobeillegalorinvalidbyacourtoflaw,thisdecision '%- shallnotaffect,impair,orinvalidatetheotherprovisionsofthisAgreement.3!L݌ T$T$ Ќ  FORTHE(INSTITUTIONNAME)  S*(1 _____________________________    ______________________ ,*3 NameofPI 4    <     Date ,`+4 ̀0  0T$T$򀀀.-6T$T$ NameofInstitutionAuthorizedSignatory    Date S/-7 Title 0/9 _ԇ FORRECIPIENTOFTHEPROTOCOL:  w 򀀀0 < 0<T$<T$0T$T$򀀀'T$T$ Patient/FamilyMemberName0 < 0<T$<T$0T$T$0DT$T$0DT$DT$Date   L    ! #XX%&fK#