AV Consent Form

OMB Control Number 0651-0080

Expiration Date: XX/XX/XXXX

Audio and Video Recording Consent Form

Thank you for volunteering to participate.

We will be recording audio and video during your session to allow the United States Patent and Trademark Office (USPTO) staff members who are unable to be here today to observe and benefit from your comments.

There will be recording of audio and video during the discussion. Audio recording will be of the discussion; video recording will be of the session visual elements (and not of individuals). These recordings will not be associated with PII data.

Please read the statement below and sign where indicated.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

I understand that this session will be recorded.

I grant USPTO permission to use this recording for internal use only.

Signature: _______________________________

Print your name: __________________________

Date: __________________

[In the case of virtual participation or telephone based group conferencing, read the above form and obtain verbal consent.]

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995, unless the information collection has a valid OMB Control Number. The OMB Control Number for this information collection is 0651-0080. Public burden for this focus group is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to the Office of the Chief Administrative Officer, United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450 or email InformationCollection@uspto.gov.