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CONSENT FOR PRODUCTION AND USE OF VERBAL OR WRITTEN STATEMENTS, PHOTOGRAPHS, DIGITAL IMAGES, AND/OR ... - page 2 / 2

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I consent to allowing VA to record and use a verbal or written statement, or produce and use photographs, digital images, and video or audio recording for the purpose(s) identified below:

This product will be used: (NOTE: At least one of these boxes must be checked as well as a purpose described below)

(to be completed by VA)

Internally (stay within VA)

Externally ( shared outside VA)

Please check the applicable purpose(s) (to be completed by VA)

Promotional Efforts: Internal Publication (only VA)

External publication (publicly available)

Other (Specify):

Research Activities:

Study

Education Purposes: Presentation

Conference

Publication in a Journal

Training

Other (Specify):

VA ONLY Use: Performance Improvement

Quality Improvement

Health Care Operations

Other (Specify):

All of the Above

NOTE: Do not sign this form unless one or more of the boxes above has been checked.

I have read and understand the foregoing, and I consent to the use of a verbal or written statement from me, and/or of my likeness and/or voice as specified for the above-described purpose(s). I understand that no royalty, fee, or other compensation of any kind will be made to me by the United States for such use. I understand that consent to obtain, produce, and/or use a verbal or written statement, photograph, digital image, and video or audio recording containing my likeness or voice is voluntary, and my refusal will not adversely affect my access to any present or future VA benefits for which I am eligible. I further understand that I may, at any time, rescind my consent prior to or during production of a photograph, digital image, or video or audio recording. I also understand that I may rescind my consent after production is complete if the burden on VA of complying with that request is not unreasonable considering the financial and administrative costs, the ease of compliance, and the number of parties involved.

Print Full Name (First and Last Name)

Signature

Date

Consent Obtained By (TO BE COMPLETED BY VA)

Print Employee Full Name

Title

Date

Signature of Person Obtaining Consent (TO BE COMPLETED BY VA)

Signature

IMPORTANT: If VA is providing or releasing any patient health or demographic information with the verbal or written statement, photograph, digital image, or video or audio recording, VA Form 10-5345, Request for and Authorization to Release Medical Records or Health Information, is required prior to the release of such data to any source outside VA.

VA FORM NOV 2014

10-3203

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