Standard Medical Release Form

OMB No. 2127-0021 Expiration date xx, xx, xxxx

Authorization For Release Of Medical Records

I hereby voluntarily give my written authorization to release a copy of my medical records relating to my treatment of injuries sustained in an accident on ___________ to the National Automotive Sampling System.

I understand that my name and all other personal identifying information will be removed from these records, which are to be used only for research purposes. The research is sponsored by the National Highway Traffic Safety Administration (NHTSA), of the U.S. Department of Transportation, in its efforts to improve crash survivability and vehicle crashworthiness.

I acknowledge that I have read this form and all questions, by me, have been answered to my satisfaction, and I hereby acknowledge that I understand its content.

Signature of Patient or Authorized Date Representative

Relationship of Authorized Representative

Witness

Paperwork Reduction Act Burden Statement

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 a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2127-XXXX. Public reporting for this collection of information is estimated to be approximately 10 minutes per response including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

NHTSA Form 1087