SECRET
Approved For Release 2003/09/09
: CIA-RDP96-00792R000500590003-6
psychological,
and/or damage to participant's 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)
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 m his absence,
his designated Acting STAR GATE Manager.
3.
(S/NF)
As
a participant
in STAR GATE,
and IAW DoD Directive
5240
1-R,
I consent to tape recording,
monitoring and
_
.
transcribing
of
all training and operations interviews m which
I
am involved as
an integral part
of the STAR GATE mission.
I
understand that these recordings are subject to being monitored
and/or transcribed by third parties not otherwise salved in
operations or training.
I waive any claim or right of ownership
to all tape recordings and transcripts made m conjunction with
nroiect STAR GATE,
with the understanding that these tape
recordings and transcripts are property of the United States
Government
(S/NF)
I
further consent to participate
in any nonintrusive
monitoring activities that are necessary for project mission
accomplishment
( s/NF/SG/LIMDIS)
I hereby acknowledge receiving formal
counseling concerning my assignment to project STAR GATE.
Basic
training and operational procedures and their purposes,
as well
as attendant discomforts,
risks and benefits have been explained
to me.
I
further understand that my participation in project
oUN
STREAK
is voluntary and that at my request
I may
it any time
e
reassigned without fear of adverse personnel action.
SIGNATURE
SIGNATURE
Signature
(Witness)
Signature
(Participant)
Name/Grade
Name/Grade
Social Security Number
Social Security Number
Position
Position
SECRET
NOT RELEASABLE TO FOREIGN NATIONALS
LIMITED DISSEMINATION
STAR GATE
Approved For Release 2003/09/09
: CIA-RDP96-00792R000500590003-6
SECRET
Approved For Release 2003/09/09
: CIA-RDP96-00792R000500590003-6
DATA REQUIRED BY THE PRIVACY ACT OF
1974
(5 U S.C.
552a)
1 .
(U)
Authority:
Title
10,
U.S.C.
Section
8012;
Title
44,
U.S.C.,
Section 3101
and EO
9397.
2.
(S/NF/SG/LIMDIS)
Principal Purpose:
To maintain
a record
of those individuals who have executed statements of
informed
consent as participants
in Project STAR GATE.
3.
(U)
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.
(U)
Mandatory
or Voluntary Disclosure:
Information
is
disclosed
on
a voluntary basis,
but withholding information will
render
it impossible
to grant an
individual access
or
participation
in the program.
SECRET
NOT RELEASABLE TO FOREIGN NATIONALS
LIMITED DISSEMINATION
STAR GATE
Approved For Release 2003/09/09
: CIA-RDP96-00792R000500590003-6
Approved For Release 2003/09/09
: CIA-RDP96-00792R000500590003-6
APPENDIX
B
Approved For Release 2003/09/09
: CIA-RDP96-00792R000500590003-6
SECRET
Approved For Release 2003/09/09
: CIA-RDP96-00792R000500590003-6
TASKING SHEET
1.
PROJECT NUMBER:
2.
VIEWER NUMBER:
.
DATE
:
4.
TASKING:
.
EVALUATION
:
6.
COMPLETION DATE:
UNCLASSIFIED WHEN BLANK
SECRET
NOT RELEASABLE TO FOREIGN NATIONALS
LIMITED DISSEMINATION
STAR GATE
APPENDIX B
Approved For Release 2003/09/09
: CIA-RDP96-00792R000500590003-6