Attachment O Navy sample form of "Consent to Participate Voluntarily in a Research, Development, Test, or Evaluation (RDT&E) Procedure," April 28, 1969 SAMPLE FORM 28 April 1969 RDT&E ACTIVITY CONSENT TO PARTICIPATE VOLUNTARILY IN A RESEARCH, DEVELOPMENT, TEST, OR EVALUATION (RDT&E) PROCEDURE DATE 1. I hereby volunteer to participate as a subject in an RDT&E procedure being conducted under Element No. , Project No., Work Unit Title ", which has been approved by (sponsoring command). I understand that the adequacy of safety measures has been certified by the Chief, Bureau of Medicine and Surgery, and that authority to use human volunteers has been granted by the Secretary of the Navy. 2. The nature and purpose of the procedures have been explained to me as follows: (See attached summary.) 3. In making my decision to volunteer, I am not relying upon any information or representation not set forth in this document, or attached summary. My consent is given as an exercise of free will, without any force or duress of any kind. I understand that my consent to participate does not constitute a release from any possible future liability by the United States attributable to the experiments. SIGNED: (TYPED NAME, RANK, RATE, OR GRADE) DATE OF BIRTH WITNESSED: (NOT DIRECTLY INVOLVED IN TEST) APPROVED: (TEST DIRECTOR) Copy to: Service record, jacket, or personnel file Enclosure (1)