GRILL FLAME VOLUNTEER CONSENT STATEMENT (U)

• Document Type: CREST
• Collection: STARGATE
• 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
• Publication Date: March 5, 1979
• Content Type: FORM

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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.
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REVIEW ON: 5 Mar 99
REASON: Para 2-301c, DOD 5200-1R
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ACSI FORM 28,A 6gvdd For Release 2004
ARMY review(s) completed.
 Approved For Release 2004/12/17 : CIA-RDP96-00788RO01100440010-2
TAB A
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 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
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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
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TAB B
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