ATTACHMENT B - VA Form 10-3203 Fill.pdf

NOTE: The execution of this form does not authorize production or use of materials except as specified below. The specified material may be produced and used by VA for authorized purposes identified below, such as education of VA personnel, research activities, or promotional efforts. It may also be disclosed outside VA as permitted by law and as noted below. If the material is part of a VA system of records, it may be disclosed outside VA as stated in the “Routine Uses” in the "VA Privacy Act Systems of Records" published in the Federal Register.

The purpose of this form is to document your consent to the Department of Veterans Affairs' (VA) request to obtain, produce, and/or use a verbal or written statement or a photograph, digital image, and/or video or audio recording containing your likeness or voice. By signing this form, you are authorizing the production or use only as specified below.

You are NOT REQUIRED TO CONSENT TO VA's REQUEST to obtain, produce, and/or use your statement, likeness, or voice. Your decision to consent or refuse will not affect your access to any present or future VA benefits for which you are eligible.

You may rescind your consent at any time prior to or during production of a photograph, digital image, or video or audio recording, or before or during your provision of a verbal or written statement. You may rescind your 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 that number of parties involved, and

CONSENT FOR PRODUCTION AND USE OF VERBAL OR WRITTEN STATEMENTS,

PHOTOGRAPHS, DIGITAL IMAGES, AND/OR VIDEO OR AUDIO RECORDINGS BY VA

(To Be Completed by the VA).

I hereby voluntarily and without compensation authorize

CHECK AT LEAST ONE OF THE FOLLOWING (to be completed by VA)

NAME OF FACILITY

NAME OF FACILITY

to produce a photograph, digital image, and/or video or audio recording of me (or of the above named individual if the individual is legally unable to give consent).

to obtain or use a verbal or written statement from me (or the of the above named individual if the individual is legally unable to give consent).

I hereby voluntarily and without compensation authorize

NAME OF INDIVIDUAL WHOSE STATEMENT, LIKENESS, OR VOICE IS REQUESTED

10-3203VA FORM

JUL 2020 Page 1

THE PHOTOGRAPH, DIGITAL IMAGE, AND/OR VIDEO OR AUDIO RECORDING WILL BE PRODUCED WHILE I AM (describe the activity or situation) (To Be Completed by the Department of Veteran Affairs, if applicable)

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):

Other (Specify):

ConferencePresentation

RESEARCH ACTIVITIES: Study

EDUCATION PURPOSES:

Publication in a Journal Training

Other (Specify):

Performance Improvement

VA ONLY USE:

Quality Improvement Health Care Operations

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 (MM/DD/YYYY)

SIGNATURE DATE (MM/DD/YYYY)

DATE (MM/DD/YYYY)PRINT EMPLOYEE FULL NAME

PRINT EMPLOYEE FULL NAME

TITLE

PERMISSION OBTAINED BY (TO BE COMPLETED BY VA)

SIGNATURE OF PERSON OBTAINED OBTAINING CONSENT (TO BE COMPLETED BY VA)

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 10-3203, JUL 2020 Page 2

VA Form 10-3203

VHA

CONSENT FOR PRODUCTION AND USE OF VERBAL OR WRITTEN STATEMENTS, PHOTOGRAPHS, DIGITAL IMAGES, AND / OR VIDEO OR AUDIO RECORDINGS BY V. A.

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs Logo.

NOTE: The execution of this form does not authorize production or use of materials except as specified below. The specified material may be produced and used by VA for authorized purposes identified below, such as education of VA personnel, research activities, or promotional efforts. It may also be disclosed outside VA as permitted by law and as noted below. If the material is part of a VA system of records, it may be disclosed outside VA as stated in the “Routine Uses” in the "VA Privacy Act Systems of Records" published in the Federal Register.

The purpose of this form is to document your consent to the Department of Veterans Affairs' (VA) request to obtain, produce, and/or use a verbal or written statement or a photograph, digital image, and/or video or audio recording containing your likeness or voice. By signing this form, you are authorizing the production or use only as specified below.

You are NOT REQUIRED TO CONSENT TO VA's REQUEST to obtain, produce, and/or use your statement, likeness, or voice. Your decision to consent or refuse will not affect your access to any present or future VA benefits for which you are eligible.

You may rescind your consent at any time prior to or during production of a photograph, digital image, or video or audio recording, or before or during your provision of a verbal or written statement. You may rescind your 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 that number of parties involved, and CONSENT FOR PRODUCTION AND USE OF VERBAL OR WRITTEN STATEMENTS, PHOTOGRAPHS, DIGITAL IMAGES, AND/OR VIDEO OR AUDIO RECORDINGS BY VA (To Be Completed by the VA).

CHECK AT LEAST ONE OF THE FOLLOWING (to be completed by VA) to produce a photograph, digital image, and/or video or audio recording of me (or of the above named individual if the individual is legally unable to give consent).

to obtain or use a verbal or written statement from me (or the of the above named individual if the individual is legally unable to give consent).

NAME OF INDIVIDUAL WHOSE STATEMENT, LIKENESS, OR VOICE IS REQUESTED

10-3203

VA FORM

JUL 2020

THE PHOTOGRAPH, DIGITAL IMAGE, AND/OR VIDEO OR AUDIO RECORDING WILL BE PRODUCED WHILE I AM (describe the activity or situation) (To Be Completed by the Department of Veteran Affairs, if applicable) 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) PLEASE CHECK THE APPLICABLE PURPOSE(S) (to be completed by VA)

PROMOTIONAL EFFORTS:

RESEARCH ACTIVITIES:

EDUCATION PURPOSES:

VA ONLY USE:

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.

SIGNATURE

DATE (MM/DD/YYYY)

SIGNATURE

DATE (MM/DD/YYYY)

DATE (MM/DD/YYYY)

TITLE

PERMISSION OBTAINED BY (TO BE COMPLETED BY VA)

SIGNATURE OF PERSON OBTAINED OBTAINING CONSENT (TO BE COMPLETED BY VA)

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 10-3203, JUL 2020