Approved For Release 2000/08/08
: (3WPWP^-00789R0026001 6001 0-6
DEFENSE INTELLIGENCE AGENCY
WASHINGTON, D.C. 20340-
STATEMENT OF CONSENT
DIA STAR GATE PROJECT PARTICIPANT
Date
:
a ss ignment^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
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 Pr°£essi °n
^?;
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.
(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,
voluntarily accept
WARNING NOTICE-INTELLIGENCE
SOURCES OR METHODS INVOLVED
CLASSIFIED BY MULTIPLE SOURCES
DECLASSIFY ON OADR
Approved For Release 2000/08/08
: CIJrt*#WW^t)789R0026001 6001 0-6
NOT RELEASABLE TO FOREIGN NATIONALS
Approved For Release 2000/08/08
: GttABBa^0789R0026001 6001 0-6
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 IAWDoD
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
: CI/sPWfiP^W)0789R0026001 6001 0-6
NOT RELEASABLE TO FOREIGN NATIONALS
Approved For Release 2000/08/08
: CIA-RDP96-00789R0026001 6001 0-6
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.
I
>
Approved For Release 2000/08/08
: CIA-RDP96-00789R0026001 6001 0-6