Approved For Release 20011 P96-00789ROO2100150015-7
                                        Or=
         GRILL FLAME VOLUNTEER CQNSENT STATEMENT SGFOIA3
         /C V ,9 /V 2) 0 V/ IV SSAN
         h;ving attained by eighteenth Cl8th) birThday- an 50 erw se
         having full capacity to consent, do hereby volunteer to
         participate in GRILL FLAME, a DOD project to determine possible
         military applications ofinherent 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.
         ,Z 72--
         (NAME) (DATE)
              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 2001/03 A-12nP96-00789ROO2100150015-7
         ly I@PZT_ - - - -,- - t - - -

         

           Approved For Release 2001/01%.@.Mfr%-00789
           1. Explanation-of experiments,. including natire,
           purpose and expected benefits. Must include
           no hypnosis, drugs, or other psychopharmacolo
           or treatment of research subjects by sublimin
           or other means of stimulation unknown to,them
           in this program. (Standard)
           2100150015.7
                duration,
           tatement that
           ical agents,
           1-technologies
           'are -@nVo1.Ved__\-_,.-'_
           2. Explanation of procedures, including meth d.s and means
           by which conducted and an indication of those methods and
           means that are experimental.
           3. Description of reasonably expected inconv@niences, hazards,
           discomfort, risks, or other effects. (Standa d)
           4. Description of any alternative procedures that might be
           employed to protect further the subject healt If none, so
           state. (Standard)
           5. Description of alternative advantages to
           (Standard)
           6. Status of volunteer's health as determi
           Include EKG results.
           7. Questions posed by volunteer and answers,
           Note: Volunteer will initial end of each oflabove
           lunteer.
           by a physician.
           paragraphs.
           Approved For Release
           4.150015-7