3 Alabama Outreach Photo Video Consent Form

OMB # 0925-0701
Expiration Date: 07/31/2017

Photo/Video Consent Form
Public reporting burden for this collection of information is estimated to average 3 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. An agency may not conduct
or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance
Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0701). Do not
return the completed form to this address.
The staff of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
would like to use a digital file (photograph, video, audio) of you/your child in an NICHD publication/Web site. As
part of the United States’ federal government, all NICHD materials are free of copyright, which means that anyone
can use the publications or Web content, in whole or in part, without notifying NICHD. Because the content will be
available on the Internet and other media platforms, it could potentially be viewed and downloaded by people
around the world, instantly and without NICHD knowledge.
NICHD requires that “written permission must be obtained from an individual before using any photograph or
graphical depiction of the individual.” If you sign this form, either for yourself or for your child, the following
conditions apply:
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I understand that by signing this form, I give NICHD permission to use my/my child’s photograph, video
recording, and/or audio recording in an NICHD publication/Web site/media platform.
I understand that the content may be available in print and electronically.
I understand that NICHD’s publications, Web site, and other products are intended for informational purposes.
I understand that no copyright applies to the photograph, video recording, or audio recording or to the
information it accompanies, and that any public person can use the content without notifying me or NICHD, of
either their intention to do so or the context of that use.
I understand that my/my child’s image may be digitally edited (for example, changing the image size, the
coloration, or the background), but that the alterations will in no way change the meaning of the image or its
intended purpose.
I understand that the NICHD will retain this consent form only; the Institute will not retain my/my child’s
personal information, nor will it provide such information to others.

I,

, agree to the conditions listed above and give my
Print Your Name Here

permission for NICHD to use my/my child’s image in NICHD health education publication(s) and other printed and
electronic formats.

Signature of Individual/Parent/Guardian

Names of All Children Being Photographed

Date