Form G253-1 Audio/Video Consent Form

OMB Control Number 0651-0080

Expiration Date: 08/31/18

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.

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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.]

This information collection contains requirements subject to the Paperwork Reduction Act (PRA). Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to penalty for failure to comply with, a collection of information subject to the requirements of the PRA, unless that collection of information displays a currently valid OMB Control Number. The estimated response time for this collection is two hours. The response time includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.