ATTACHMENT C
RELEASE FORM
Use of Audio or Video Recording for Academic Presentations
I, _____________________________________________________, give permission to the National Cancer Institute (NCI) to use the videotape image of me and/or the audiotape of my voice made during the research session on ______________ [Date] for the purpose of research related to “Playing for Life: Reducing the Negative Impact of Tobacco on Youth and Young Adults through Video Games, Gaming, and Gamification”. This research is being done in collaboration with the University of Florida. I understand that this image or audiotape might be used as part of an academic or scholarly presentation and could be seen or heard by researchers at NCI or the National Institutes of Health, other academics doing research in cancer-related issues, and/or students in fields such as public health, health communication, or information technology. I understand that any other identifiers of mine besides my name and professional title (such as my age, city of residence) will not be revealed or released along with my image or voice. I also understand that the videotape and/or the audiotape of me will never be posted on the NCI website or used for other general release publications.
_____ I AGREE TO RELEASE MY IMAGE/VOICE RECORDING FROM THIS SESSION:
SIGNATURE: _____________________________ ________________________
PRINT NAME: _____________________________________________________
DATE:______________________
_____ I DO NOT AGREE TO RELEASE MY IMAGE/VOICE RECORDING FROM THIS SESSION:
SIGNATURE: _____________________________ ________________________
PRINT NAME: _____________________________________________________
DATE:______________________
If you have any questions or concerns after you are finished you may contact:
Dr. Jay Bernhardt at 352-294-1800 or email [email protected] or
Dr. Tracey Barnett at 352-273-6745 or email [email protected].
You may also contact Institutional Review Board (IRB02) office at the University of Florida:
(352) 392-0433.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | ATTACHMENT C |
| Author | NCI |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |