Approved For Release 2000/08/08 : C@BM98-00789R002600160010-6 DEFENSE INTELLIGENCE AGENCY WASHINGTON, D.C. 20340- STATEMENT OF CONSENT DIA STAR GATE PROJECT PARTICIPANT Date: 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 Approved For Release 2000/08/08 : CH@M¥YBIID789R002600160010-6 NOT RELEASABLE TO FOREIGN NATIONALS
Approved For Release 2000/08/08 : Cénpaiaititiitiel) 0789R002600160010-6 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 Approved For Release 2000/08/08 : ClA@@SF8S-00789R002600160010-6 NOT RELEASABLE TO FOREIGN NATIONALS
Approved For Release 2000/08/08 : CIA-RDP96-00789R002600160010-6 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. | 1 ! | { | | i Approved For Release 2000/08/08 : CIA-RDP96-00789R002600160010-6