STATEMENT OF CONSENT: DIA STAR GATE PROJECT PARTICIPANT

• Document Type: CREST
• Collection: STARGATE
• Document Number (FOIA) /ESDN (CREST): CIA-RDP96-00789R002600160010-6
• Release Decision: RIFPUB
• Original Classification: S
• Document Page Count: 3
• Document Creation Date: November 4, 2016
• Document Release Date: December 4, 1998
• Sequence Number: 10
• Content Type: CONT

Approved For Release 2000/08/08 : LUu-00789R002600160010-6
DEFENSE INTELLIGENCE AGENCY
WASHINGTON, D.C. 20340-
STATEMENT OF CONSENT
DIA STAR GATE PROJECT PARTICIPANT
1. (S/NF/WN) I, voluntarily accept
assignment to the DIA STAR GATE Project and fully understand
that:
a. (S/NF/WN) The DIA and DoD General Counsels have
determined that the STAR GATE Project constitutes experimentation
on human subjects. As required by Procedure 13 of DoD Directive
5240.1-R, approval for project activities has been granted by the
Deputy Secretary of Defense.
b. (S/NF/WN) The aim of STAR GATE is to develop highly
skilled personnel who are capable of conducting professional
level intelligence/counterintelligence operations through the use
of psychoenergetics methodology. Development of STAR GATE will
be accomplished with special training based on mission
requirements.
c. (C/NF) Assignments in STAR GATE 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/NF) The primary consideration in any career
development or assignment action will be STAR GATE 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.
2. (U) PSYCHOENERGETICS (PE) include various processes by which
individuals psychically interact with objects, locations, and
organisms.
a. (U) I understand that while there is no demonstrated risk
of permanent or temporary injury (including physical,
WARNING NOTICE-INTELLIGENCE
SOURCES OR METHODS INVOLVED
CLASSIFIED BY MULTIPLE SOURCES
DECLASSIFY ON OADR
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NOT RELEASABLE TO FOREIGN NATIONALS
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psychological and/or damage to participants' reputation) to
project personnel beyond risks to which they would ordinarily be
exposed in their daily lives, the potential for injury during
some training cannot be conclusively ruled out.
b. (S/NF/WN) I may temporarily choose not to participate in
the project at specific times, or permanently discontinue
participation without prejudicial effect. Termination will be
affected by notifying the STAR GATE Manager or in his absence,
his designated acting STAR GATE Manager.
3. (S/NF/WN) As a participant is STAR GATE, 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 STAR GATE mission. I
understand that these recording 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 inconjunction with
STAR GATE, with the understanding that these tape recordings and
transcripts are property of the United States Government.
4. (S/NF/WN) I further consent to participate in any
noninstrusive biomonitoring activities that are necessary for
project mission accomplishment.
5. (U) I hereby acknowledge receiving formal counseling
concerning my assignment to STAR GATE. 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
STAR GATE is voluntary and that at my request I may at any time
be reassigned without fear of adverse personnel action.
SIGNATURE: SIGNATURE:
Signature (Witness) Signature (Participant)
Name, Rank/Grade Name, Rank/Grade
Social Security Number Social Security Number
Position Position
WARNING NOTICE-INTELLIGENCE
SOURCES OR METHODS INVOLVED
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NOT RELEASABLE TO FOREIGN NATIONALS
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DATA REQUIRED BY THE PRIVACY ACT OF 1974 (5 U.S.C. 552a)
1. Authority: Title 10, U.S.C. Section 8012; Title 44, U.S.C.,
Section 3101 and EO 9397.
2. Principal Purpose: To maintain a record of those individuals
who have executed statements of informed consent as participants in
DSSP.
3. Routine Uses: The Social Security Number is to be used to
identify the individual, and the information is to be retained
strictly within the program.
4. Mandatory or Voluntary Disclosure: Information is disclosed on
a voluntary basis, but withholding information will render it
impossible to grant an individual access to or participation in the
program.
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