•
Approved For F^t
CONTROL NUMBER
100440010-2
SU&JECT
OFFICE SYMBOL
1 S US PE NS E
DAMI-ISH
I
GRILL FLAME Volunteer
Consent
Statement
(U)
DATE
5 Mar
ACTION REQUIRED
|
OGC Approve Draft
Consent
Statement
at JAB
a
(u)
MEMORANDUM FOR RECORD.
( Describe briefly the requirement , background and action taken or recommended. Must be sufficiently detailed to identify
ike action without recourse to other sources .
)
!•
(C)
BACKGROUND :
At TAB
B 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)
RE COMMENDAT I ON
:
OGC approve
draft
consent
statement
at tab a_
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.
mm,mw i)
©Mil ffiSJ/MGi
CLASSIFIED
BY:
DIA-DT
REVIEW ON:
5 Mar
REASON:
Para 2-30 lc,
DOD 5200- 1R
#3
(Continue on plain bond)
ACSI FORM 28,Ajfc$>fe|v5dl For Release 2004
ARMY review(s) completed.
5-°^Mirar
788R00m02f4001 0-2
WHEN SEPARATED FROM CLASSIFIED
DOCUMENT
Approved For Release 2004/12/17
: CIA-RDP96-00788R001 10044001 0-2
TAB A
Approved For Release 2004/12/17
: CIA-RDP96-00788R001 10044001 0-2
-00788R001 10044001 0-2
Approved For Release 2004/1
GRILL FLAME VOLUNTEER CONSENT STATEMENT
I,
___
,
SSAN
,
having attained by eighteenth
( 18 th)
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,
n
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 2004/1
®S-00788R001 1 0044001 0-2