Appendix J
Talent and Consent Waiver
Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/20xx
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH
TALENT AND CONSENT WAIVER
TO WHOM IT MAY CONCERN:
I hereby grant full permission to the Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, to use, reproduce, publish, distribute, and exhibit my name, picture, portrait, likeness, voice or any or all of them in or in connection with the production of a television tape or film recording, video tape, sound track or audio recording, motion picture film, filmstrip, or still photograph, in any manner for training and other purposes.
Without limitation as to time, I hereby waive all rights for compensation in connection with the use of my name, picture, portrait, likeness or voice, or any or all of them, in or in connection with said television tape or film recording, video tape, sound track or audio recording, motion picture film, filmstrip, or still photograph, in whole or in edited form and any use to which the same or any material therein may be put, applied or adapted by the United States Government and others in the health field.
IN WITNESS WHEREOF I have hereunto set my hand and seal this day of _______________ 20 .
CDC estimates the average public reporting burden for this collection of information as 6 minutes 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 this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
NAME (print)
SIGNATURE_____________________________________
WITNESS:
SIGNATURE
DATE:
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Foley, Tamekia (CDC/NIOSH/OD) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |