Informed Consent of Joint Civilian Orientation Conferenc

INFORMED CONSENT

of Joint Civilian Orientation Conference (JCOC) Participant

for DoD use of photographs, and visual and audio recordings

I, ________________________________, a participant in the Joint Civilian Orientation Conference (JCOC), provide my consent for the Department of Defense (DoD) and its Components, to use, reproduce, publish, broadcast, transmit, and distribute, my photograph and visual and audio recordings of me taken in connection with the JCOC, for DoD public affairs and news dissemination purposes on DoD and DoD component websites and for other Internet-based activities where DoD maintains an external official presence (e.g., official DoD social media accounts on services such as Facebook, Twitter, Instagram, etc.).

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Signature Date

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 113, Secretary of Defense; DoD Directive 5122.05, Assistant Secretary of Defense for Public Affairs (ASD/PA); DoD Directive 5410.18, Public Affairs Community Relations Policy; and DoD Instruction 5410.19, Public Affairs Community Relations Policy Implementation.

PRINCIPAL PURPOSE(S): To ensure informed consent by participants in the JCOC concerning DoD’s use, reproduction, broadcast, transmittal, and distribution of participant’s photograph(s) or other recorded visual or audio footage taken in connection with the JCOC for public affairs and news dissemination purposes on DoD and DoD component websites and for other Internet-based activities where DoD maintains an external official presence (e.g., official DoD social media accounts on services such as Facebook, Twitter, Instagram, etc.).

ROUTINE USE(S): Applicable Routine Use(s) are: Law Enforcement Routine Use, Congressional Inquiries, Disclosure to the Department of Justice for Litigation Routine Use, Disclosure of Information to the National Archives and Records Administration Routine Use, and Data Breach Remediation Purposes Routine Use. The DoD Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems of records notices may apply to this system. The complete list of DoD Routine Uses can be found online at:

http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx.

The applicable system of records notice is DPA 03, Joint Civilian Orientation Conference (JCOC) Program and can be found online at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570580/dpa-dcra-01/

DISCLOSURE: Voluntary; however, failure to complete this form will result in limiting DoD’s ability to use a photograph, visual or audio recording of participant for public affairs and news dissemination purposes.