Attachment 13

Attachment 13

Photographic release form

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

TALENT AND CONSENT WAIVER

TO WHOM IT MAY CONCERN:

I hereby grant full permission to the Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, to use, reproduce, publish, distribute, and exhibit my name, picture, portrait, likeness, voice or any or all of them in or in connection with the production of a television tape or film recording, video tape, sound track or audio recording, motion picture film, filmstrip, or still photograph, in any manner for training and other purposes.

Without limitation as to time, I hereby waive all rights for compensation in connection with the use of my name, picture, portrait, likeness or voice, or any or all of them, in or in connection with said television tape or film recording, video tape, sound track or audio recording, motion picture film, filmstrip, or still photograph, in whole or in edited form and any use to which the same or any material therein may be put, applied or adapted by the United States Government and others in the health field.

IN WITNESS WHEREOF I have hereunto set my hand and seal this day of 20 .

NAME (print)

ADDRESS

SIGNATURE_____________________________________

WITNESS:

SIGNATURE

DATE:

CDC 37.6 (f.61.2)

Rev. 8/03

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