Appendix 5-C. AHRQ Public Service Announcement Release Form

TALENT RELEASE FORM
Agency for Healthcare Research Quality (AHRQ)
U.S. Department of Health & Human Services
Public Service Announcement about __________
Production Date: __________

PLEASE PRINT

NAME:

ADDRESS:

PHONE NUMBER:

EMAIL ADDRESS:

I hereby grant to the Agency for Healthcare Research Quality ("AHRQ") and [list any other offices or partners]¹ their assignees, successors, and those acting in pursuant to their authority:

(1) The right and permission to use, copyright, and publish photographs, or videos of me, whether alone or with any other material, for informational or promotional purposes;

(2) The right and permission to use, copyright, and publish recordings of my voice, whether alone or with any other material, for informational or promotional purposes; and

(3) The right and permission to use and publish my name, biographical information, and/or other identifying material in conjunction with photographs or videos of me, or recordings of my voice.

This release covers use of the above-mentioned material by AHRQ and [list any other offices or partners] in any broadcast, cable, Web sites, other private audio or video networks, or within other informational or promotional materials prepared by AHRQ and [list any other offices or partners] for distribution, without profit to the AHRQ or [list any other offices or partners]. It is understood no compensation,² royalties or residuals will be paid.

I warrant that I am over the age of 18 years³ and that I am free to enter into this Agreement.

SIGNATURE: _______________________________________________________________   DATE: ______________________