Appendix 5-D. AHRQ Talent Release Form

TALENT RELEASE FORM
Agency for Healthcare Research Quality (AHRQ)
U.S. Department of Health & Human Services

I do hereby authorize AHRQ, assignees, successors, and those acting pursuant to its authority to:

(1) Record my participation and appearance at this meeting on videotape, audiotape, file, photograph, or other medium.

(2) Use my name, likeness, voice, CV, and biographical material in connection with or promotion of these recordings.

(3) Exhibit, broadcast, Webcast, store and forward, copy, edit, and/or distribute such recording in whole or in part without restriction or limitation for any educational, commercial, or promotional purpose which AHRQ, assignees, successors, and those acting pursuant to its authority, deem appropriate.

(4) No royalties, compensation, or residuals will be paid.

(5) I hereby waive any right to inspect and approve the rough cut, promotional, or finished product.

NAME: __________________________________________________________________

ADDRESS: ______________________________________________________________

PHONE NUMBER:_____________________ EMAIL:______________________________

SIGNATURE: _____________________________________________________________