Photo Consent

Attachment H:

Consent of Photographic Image Release

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

(Note that Toyota management must also approve the release of any photo video image)

General Photo/Video Release

1. I agree to allow the National Institute for Occupational Safety and Health (NIOSH) to use my photographic image.

I hereby agree to allow my photographic image to be used (with or without name, both singly and in conjunction with other persons or objects) by NIOSH.

I hereby agree to allow my video recorded image to be used (with or without name, single or in conjunction with other persons or objects) by NIOSH.

2. NIOSH will use my photographic image (still photograph and/or video image for any or all of the following:

a. Obtaining research data regarding the work process.

b. Use in publications and presentations (print and/or video) describing research methodology and results.

c. Production of training materials or materials describing the work process.

d. Other purposes.

I understand that NIOSH publications are printed by the United States Government Printing Office without copyright protection and may be distributed free or sold. I also understand that additional printings may be conducted by the United States Government Printing Office in the future. I understand that other persons will be allowed to make copies of these government publications.

3. No one will ever pay me for the use of my photographic image.

I understand that for the use of my photographic image, I will receive no financial compensation or payment of any kind from the United States Government or from any agency of the Government or from any person making a copy of the government publication now or at any time in the future.

Public reporting burden of this collection of information is estimated to average 2 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

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Signature Date

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Printed Name

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Address

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Telephone