GRILL FLAME VOLUNTEER CONSENT STATEMENT (U)

Document Type: 
Collection: 
Document Number (FOIA) /ESDN (CREST): 
CIA-RDP96-00788R001100440010-2
Release Decision: 
RIPPUB
Original Classification: 
S
Document Page Count: 
6
Document Creation Date: 
November 4, 2016
Document Release Date: 
June 17, 1998
Sequence Number: 
10
Case Number: 
Publication Date: 
March 5, 1979
Content Type: 
FORM
File: 
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PDF icon CIA-RDP96-00788R001100440010-2.pdf166.12 KB
Body: 
D~ A d F RM TA 2 ~1~1/17WA FN@F004 CONTROL NUMBER 00440010 2 pprove or I p - SU JECT OFFICE SYMBOL SUSPENSE DAMI-ISH GRILL FLAME Volunteer Consent Statement (U) DATE 5 Mar 79 ACTION REQUIRED OGC Approve Draft Consent Statement at TA,~--B_A_ U MEMORANDUM FOR RECORD. (Describe briefly the requirement, background and action taken or recommended. Must be sufficiently detailed to identify the action without recourse to other sources.) 1. (C) BACKGROUND: At TAD __D is OGC legal directive/ pertaining to GRILL FLAME. In the memorandum, and conversations with OGC representative, it is directed that a volunteer consent statement, as prescribed by HEW regulation and AR 70-25, will be required of any person actively engaged as a "sensor" in a GRILL FLAME experi- ment/test/activity. 2. (U) DISCUSSION: a. (U) The draft consent statement at TAB-A is consistent with the aforemen- tioned guidelines. b. (U) It will be dispatched to Army field activities immediately upon OGC concurrence. c. (U) The time factor is becoming increasingly sensitive since all work on GRILL FLAME shut down some weeks ago, pending resolution by OGC of the legal issues. d. (U) This consent form will be standard for all Army elements. 3. (U) RECOMMENDATION: OGC approve draft consent statement at Tom. . ADDENDUM: The form will be reviewed in each case by the Human Use Testing Committee and the information on back.may be amended by the committee; the forms will not be signed until after committee approval. ~~~~nLb ~a fry;~ CLASSIFIED BY: DIA-DT L MJ ~J REVIEW ON: 5 Mar 99 REASON: Para 2-301c, DOD 5200-1R IJL,WE molm / n1ffl ~G - 1W W ll uuW 11 #3 (Continue on plain bond) IMPLICATIONS CINFO YES NO PRIM PROGS YES NO ^ BUDGET YES NO COORDINATIONS APPROVALS OFFICE NA E PHONE INITIALS DATE 6~. r 46 '77 8 B R DIV DIR EX ACS I DISPATCHED (DT G) -' SHOW ADD IT ION AL COORDINAT ION ON REVERSE SIDE OR CONTINUATION SHEET REGRADED 0.sli'~stlcwx~d'~u~ S' WHEN SEPARATED rR0I 1. ACTION OFFICER (Name, grade, ne and f r.) Ci Iq,I '' ~. ?`S t"^sIr"~D MAJ Stoner/55048 ACSI FORM 28,A 6gvdd For Release 2004 ARMY review(s) completed. Approved For Release 2004/12/17 : CIA-RDP96-00788RO01100440010-2 TAB A Approved For Release 2004/12/17 : CIA-RDP96-00788RO01100440010-2 Approved For Release 2004/1V-007888001100440010-2 GRILL FLAME VOLUNTEER CONSENT STATEMENT I, - _ , SSAN having attained by eighteenth (18th) birthday and otherwise having full capacity to consent, do hereby volunteer to participate in GRILL FLAME, a DOD project to determine possible military applications of inherent psychic abilities. The fol- lowing items have been explained to me by and are set forth on the reverse side of this Agreement, which I have initialed: a. The nature, duration, purposes, and expected benefits of the program in which I will be participating; b. The methods and means by which the program is to be conducted; any methods and means that are experimental will be identified as such; c. The inconveniences, hazards, discomforts, risks or other effects on my health or person which may possibly come from my participation in the program; d. The alternative procedures, if any, that might, be employed to protect further my health and well-being.`'I have been given an opportunity to ask questions concerning this project and any such questions have been answered to my full and complete satisfaction. I understand that I may at any time during the course of this project revoke my consent and withdraw from the study without prejudice; however, I may be requested to undergo certain further examinations, if, in the opinion of a qualified physician, such examinations are neces- sary for my health or well-being. (NAME) (DATE) I was present during the explanation referred to above, as well as the volunteer's opportunity for questions, and hereby witness his signature. I am not involved in the GRILL FLAME program in any way. (NAME) (DATE) Approved For Release 2004/127 Approved For Release 200 C. I " 1. Explanation of experiments, including nature, duration, purpose and expected benefits. Must include statement that no hypnosis, drugs, or other psychopharmacological agents, or treatment of research subjects by subliminal technologies or other means of stimulation unknown to them, are :involved--A.' in this program. (Standard) 2. Explanation of procedures, including methods and means by which conducted and an indication of those methods and means that are experimental. 3. Description of reasonably expected inconveniences, hazards, discomfort, risks, or other effects. (Standard) 4. Description of any alternative procedures that might be employed to protect further the subject health. If none, so state. (Standard) 5. Description of alternative advantages to volunteer. (Standard) 6. Status of volunteer's health as determined by a physician. Include EKG results. 7. Questions posed by volunteer and answers. Note: Volunteer will initial end of each of above paragraphs. Approved For RWff WRCfAftft:~Pff pPa6 8 11M000444~0010-2 Approved For Release 2004/12/17 : CIA-RDP96-00788RO01100440010-2 TAB B Approved For Release 2004/12/17 : CIA-RDP96-00788RO01100440010-2 FOIAB5 Approved For Release 2004/12/17 : CIA-RDP96-00788R001100440010-2 Next 2 Page(s) In Document Exempt Approved For Release 2004/12/17 : CIA-RDP96-00788R001100440010-2