CONSENT OF (Name)
CONSENT FOR USE OF PICTURE AND/OR VOICE
NOTE: The information requested on this form is solicited under the authority of title 38, United States Code. The execution of this form does not authorize disclosure of the materials specified below except for the purpose(s) stated. The specified material may be used within the VA for authorized purposes, such as for education of VA personnel or for VA research activities. It may also be disclosed outside the VA as permitted by law. If the material is part of a VA system of records, it may be disclosed outside the VA as stated in the 'Routine Uses' in the "VA Privacy Act Systems of Records" published in the Federal Register. A copy of the 'Routine Uses' is available upon request to the administrative office of the VA facility involved. You do not have to consent to have your picture or voice taken, recorded, or used. Your refusal to grant your consent will have no effect on any VA benefits to which you may be entitled.
I hereby voluntarily and without compensation authorize pictures and/or voice recording(s) to be made of me (or of the above-name individual if the individual is legally unable to give consent) by (specify the name of the VA facility, newspaper, magazine, television station, etc.)
While I am (describe the activity, if any to be photographed or recorded)
I authorize disclosure of the picture and/or voice recording to (specify name and address of the organization, agency, or individual(s) to whom the release is to be made)
I understand that the said picture, video and/or voice recording is intended for the following purpose(s):
I have read and understand the foregoing and I consent to the use of my picture and/or voice as specified for the above-described purpose(s). I further understand that no royalty, fee or other compensation of any character shall become payable to me by the United States for such use. I understand that consent to use my picture, video and/or voice recording is voluntary and my refusal to grant consent will have no effect on any VA benefits to which I may be entitled. I further understand that I may at any time exercise the right to cease being filmed, photographed or recorded, and may rescind my consent for up to a reasonable time before the picture, video or voice recording is used.
SIGNATURE OF INDIVIDUAL OR OTHER LEGALLY AUTHORIZED PERSON DATE
PERMISSION OBTAINED BY (NAME - TITLE - ADDRESS)
SIGNATURE OF INTERVIEWER OR INDIVIDUAL OBTAINING CONSENT
INDIVIDUAL' S NAME AND ADDRESS
IMPORTANT: This form must always be completed prior to the making or using pictures, video or voice recording(s) of any VA patient. If any patient health or demographic information is to be provided or released with the picture, video or voice 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.
VA FORM MAY 2005