PROPOSED STATEMENT OF CONSENT

• Document Type: CREST
• Collection: STARGATE
• Document Number (FOIA) /ESDN (CREST): CIA-RDP96-00788R001500160009-1
• Release Decision: RIPPUB
• Original Classification: S
• Document Page Count: 5
• Document Creation Date: November 4, 2016
• Document Release Date: September 5, 2003
• Sequence Number: 9
• Publication Date: April 15, 1985
• Content Type: STATEMENT

Approved For Release 2 I - 6-00788R001500160009-1
UNITED STATES GOVERNMENT
RFPLYTO
ATTN OF:
15 April 1985
DIA/DT
Proposed Statement of Consent
memorandum
DIA/GC
TO: G C
1. (S/NF/WNINTEL) Attached is a revised Statement of Consent
prepared IAW Procedure 13, DoD Directive 5240.1.-R for use by
participants in the DIA DRAGOON ABSORB Project. The Statement
of Consent was prepared in accordance with guidelines issued by
the Department of Health and Human Services. Specifically,
guidelines under section 46.116, Subpart A, Part 46, Title 45,
Code of Federal Regulations were used to prepare the statement.
2. (U) Request your review of the Statement of Consent for
compliance with DoD Directive 5240.1-R
3. (U) POC is LTC Brian Buzby, AVN 923-7829/2656.
2 Encl
1. Statement of Consent
2. 45 CFR 46 (extract)
SG1J CF
t,/ DT-5A
UAW` J
BRIAN BUZBY
LTC, US Army
CLASSIFIED BY: DIA/DT
DECLAS: OADR
f ..W'flNGNOTICE: SENSITII/B
"A l..IGENCE SCURccS?ANQ:
Pvi~
pp~p~+pp ray 1VX~.~J: J:Y - I HODS INVOLVRQ
a ? .L ~1tli1.:?a~yy+~tLY',lY NAT OPTIONAL FORM NO. 10
Approved For Release 2003/09/09 : CIA-RDP96-00788 R001500160001?N r-SO)
S9A F'PAAR (41 CFi3) 101-11.8
IOIQ 114
EC R t I
 Approved For Release ?t~i : C A- 96-00788ROO 1500160009-1
DEFENSE INTELLIGENCE AGENCY
WASHINGTON. D.C. 20301-6111
STATEMENT OF CONSENT
DIA PROJECT PARTICIPANT'
1. (S/NOFORN/WNINTEL) T, voluntarily
accept assignment to the DIA and fully
understand that:
Counsels have
determined that the DDAP constitutes experimentat..un on human
subjects. As required by Procedure 13 of DoD Directive 5240.1.-R,
the Deputy Secretary of. Defense has granted approval for the conduct
of DDAP activities.
a. (S/NOFORN/WNINTEL)
b. (S/NOFORN/WNINTEL) The mission of the DDAP is to collect
intelligence information through the use of pscychoenergetic
methodology. Development and use of DDAP operational intelligence
collection personnel will be accomplished with special training
based on mission requirements in accordance with established
procedures.
c. (C/NOFORN) Assignments in DDAP are governed by the
sensitivity and degree of expertise required for the position. I
will be assigned in accordance with my capabilities and experience,
regardless of my rank or previous position. Due to the nature of
training involved, the duration of my participation is indefinite.
Records of my involvement will be available to project personnel,
but otherwise protected under project security measures.
d. (C/NOFORN) The primary consideration in any career
development or assignment action will be DDAP mission and
operational requirements. I understand that exemption,
interruption, or delay in normal career development patterns--such
as branch schooling and assignment opportunities--may prejudice
future promotion and assignment potential. I have been assured,
however, that every effort will be made to preclude the adverse
effects listed above on my career.
e. (S/NOFORN/WNINTEL) I understand that there is no
demonstrated risk of permanent or temporary injury (including
physical., psychological and/or damage to participants' reputation)
to project personnel beyond risks to which they would ordinarily be
exposed in their daily lives. However, I understand further that
potential. for injury during some training cannot be conclusively
ruled out.
CLASSIFIED BY: DIA/DT
DECLAS: OADR
Approved For Re1 ease01/C191?Cti~~R001500160009-1
a
'I'M MG NOTICE: SEiVSI7,NEJ'
''LLIGENCE SOURCF,-~.ANQ
 Approved For Release R-i-OO788ROOl5OOl6OOO9-l
f. (S/NOFORN/WNINTEL) I may temporarily choose not to
partiepate in the project at specific times, or permanently
discontinue participation without prejudicial effect. Termination
will be affected by notifying the Commander, Prototype Operational
Group (POG), DSSP, or his designated representative.
2. (S/NOFORN/WNINTEL) As a participant in DSSP, and IAW DoD
Directive 5240.1-R, I consent to tape recording, monitoring and
transcribing of all training and operational interviews in which I
am involved as an integral part of the DSSP mission. I understand
that these recordings are subject to being monitored and/or
transcribed by third parties not otherwise involved in operations or
training. I waive any claim or right of ownership to all tape
recordings and transcripts made in conjunction with DSSP, with the
understanding that these tape recordings and transcripts are
property of the United States Government.
3. (C/NOFORN) I hereby acknowledge receiving formal counseling
concerning my assignment to DSSP. Basic training and operational
procedures and their purposes, as well as attendant discomforts,
risks, and benefits have been explained to me. I understand that I
may at any time ask questions of the Commander, POG, or other
appropriate project personnel relating to areas unclear to me. I
further understand that my participation in DSSP is voluntary and
that at my request I may at any time be reassigned without fear of
adverse personnel action.
Signature T Witne Ss) Signature ark -z ant)-
oc al Security 1Vu er- Social Security Number
SECRET
Name, Rank/Grade`~__ Name, Rank Grade
Approved For Release 2003/09/09 : CIA-RDP96-00788 R001500160009-1
 Approved For Release SEC:REi6-OO788ROOl 500160009-1
DEFENSE INTELLIGENCE AGENCY
WASHINGTON. D.C. 20301-6111
STATEMENT OF CONSENT
DIA SUN STREAK PROJECT PARTICIPANT
1. (S/.NOFORN/WNINTEL) I, _ voluntarily
accept assignment to the DIA SUN STREAK PROJECT DSSPT and fully
understand that:
a. (S/NOFORN/WNINTEL) The DIA and DoD General Counsels have
determined that the DSSP constitutes experimentation on human
subjects. As required by Procedure 13 of DoD Directive 5240.l-R,
the Deputy Secretary of Defense has-granted approval for the conduct
of DSSP activities.
b. (S/NOFORN/WNINTEL) The mission of the DSSP is to collect
intelligence information through the use of pscychoenergetic
methodology. Development and use of DSSP operational intelligence
collection personnel will be accomplished with special training
based on mission requirements in accordance with established
procedures.
c. (C/NOFORN) . Assignments in DSSP are governed by the
sensitivity and degree of expertise required for the position. I
will. be assigned in accordance with my capabilities and experience,
regardless of my rank or previous position. Due to the nature of
training involved, the duration of my participation is indefinite.
Records of my involvement will be available to project personnel,
but otherwise protected under project security measures.
d. (C/NOFORN) The primary consideration in any career
development or assignment action will be DSSP mission and
operational requirements. I understand that exemption,
interruption, or delay in normal career development patterns--such
as branch schooling and assignment opportunities--may prejudice
future promotion and assignment potential. I have been assured,
however, that every effort will be made to preclude the adverse
effects listed above on my career.
e. (S/NOFORN/WNINTEL) I understand that there is no
demonstrated risk of permanent or temporary injury (including
physical, psychological and/or damage to participants' reputation)
to project personnel beyond risks to which they would ordinarily be
exposed in their daily lives. However, I understand further that
potential for injury during some training cannot be conclusively
ruled out.
CLASSIFIED BY: DIA/DT
DECLAS : OADR
Approved For Release 2003/69161P {i Z'I 6''00788ROO1500160009-1
itNUNG NO I"ICE. SENSITNE,,
AV% VOW ? " LIGENCE SOURCES I~NQ
 Approved For Release 6-00788R001500160009-1
4~:RE
f. (S/NOFORN/WNINTEL) I may temporarily choose not to
particpate in the project at specific times, or permanently
discontinue participation without prejudicial. effect. Termination
will be affected by notifying the Commander, Prototype Operational
Group (POG), DDAP, or his designated representative.
2. (S/NOFORN/WNINTEL) As a participant in DDAP, and IAW DoD
Directive 5240.1-R, I consent to tape recording, monitoring and
transcribing of all training and operational interviews in which I
am involved as an integral part of the DDAP mission. I understand
that these recordings are subject to being monitored and/or
transcribed by third parties not otherwise involved in operations or
training. I waive any claim or right of ownership to all tape
recordings and transcripts made in conjunction with DDAP, with the
understanding that these tape recordings and transcripts are
property of the United States Government.
3. (C/NOFORN) I hereby acknowledge receiving formal counseling
concerning my assignment to DDAP." Basic training and operational
procedures and their purposes, as well as attendant discomforts,
risks, and benefits have been explained to me. I understand that I
may at any time ask questions of the Commander, POG, or other
appropriate project personnel rel..ating to areas unclear to me. I
further understand that my participation in DDAP is voluntary and
that at my request I may at any time be reassigned without fear of
adverse personnel action.
Signature jai.tne)
--- Name,-Rank%'irrdae_._.
Signature '(Farticpant
Name,^-Rank Grafe
Social Security Number Social Security Number .
Approved For Release 2003/09/09 : CIA-RDP96-00788 R001500160009-1