Form Approved
OMB No. 0920-0879
Expiration Date 01/31/2021
Name
Email address:
Health department:
Which group interview discussion would you like to participate in?
Small LHDs (<50,000) <<Insert date and time>>
Medium LHDs (50,000-500,000) <<Insert date and time>>
Large LHDs (>500,000) <<Insert date and time>>
PHEP Recipients <<Insert date and time>> (for a complete list of PHEP Recipients, click here)
Please enter your electronic signature and date if you agree to the consent and waiver form attached here:
NATIONAL ASSOCIATION OF COUNTY & CITY HEALTH OFFICIALS
MEDICAL COUNTERMEASURE (MCM) TRAINING NEEDS ASSESSMENT
RECORDING CONSENT AND WAIVER FORM
I hereby give the National Association of County & City Health Officials (NACCHO) permission to record my name, voice, likeness, and any and all attributes of my personality electronically during an online group interview. I understand that the recording will be stored on a secure, password protected server. NACCHO has my permission to use the recording to gather data for the MCM Training Needs Assessment. I understand that any data collected during the online interview or from the recording of the group interview will be shared only in aggregate form and I will not be individually identifiable. NACCHO has my permission to collect data in aggregate form from the recording and edit, publish, print, or create derivative works of the data for training and any other lawful government purpose, and to authorize others to do the same.
I waive any right that I may have to inspect and approve the finished product that may be used or to which it may be applied now and/or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the recording or product.
I release and agree to hold harmless National Association of County & City Health Officials, officers, employees, faculty, agents, nominees, departments, and/or others for whom or by whom National Association of County& City Health Officials is acting, of and from any liability by virtue of recording of video or using the testimonial/biographical data, in any progressing tending towards the completion of the finished product, and/or any use whatsoever of such products, whether intentional or otherwise.
Signature____________________________________________
Date___________________________________
Printed Name _________________________________________
Thank you for your interest in participating in a group interview discussion. You will receive a confirmation email from NACCHO with instructions for joining the discussion by [one week prior to group interview]. For any questions or concerns, please email [email protected].
CDC estimates the average public reporting burden for this collection of information as 1 minute per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Flanagan, Elizabeth (CDC/OPHPR/DSLR) |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |