AHRQ Publishing and Communications Guidelines

Appendix 1-A. Permission Forms and Licensing Agreement

This appendix contains:

*Note: Grantees may use these forms if they do not have forms of their own; however, grantees are not required to use these versions, nor are they required to send signed copies to AHRQ.

Permission Form for AHRQ To Use Copyrighted Material

Use this form when requesting use of copyrighted materials from publishers or authors. Some publishers have their own forms to request use of copyrighted materials. Provide copies of signed forms to the managing editor.

Permission Form for AHRQ To Use Copyrighted Material

The undersigned hereby grants permission to the Agency for Healthcare Research and Quality (AHRQ), located at 5600 Fishers Lane, Rockville, MD 20857, to use the material specified below and copyrighted by me:

______________________________________________________________________

These copyrighted items may be used in both print and electronic formats, including future editions.

The above permission to AHRQ shall in no way restrict republication by me of the copyrighted items in other works.

AHRQ will use the following credit line for each item that I hold copyright to:

______________________________________________________________________

_______________________________         __________________

            Copyright holder                                     Date

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Release Form for Photographs and Audiovisual Materials

This form is used to obtain permission to record a person’s appearance on video, audio, photograph, or other medium. It is used only once, as the form notes that permission is granted in perpetuity.

Release Form for Photographs and Audiovisual Materials

I hereby grant, in perpetuity, to the Agency for Healthcare Research and Quality (AHRQ), permission to:

  • Record my participation and appearance on video, audio, photograph, or other medium.
  • Use my name, likeness, voice, biographical information, and other identifying material in connection with or promotion of these recordings or photographs.
  • Exhibit, broadcast, webcast, store and forward, copy, edit, or distribute such materials in whole or in part without restriction or limitation, for any informational, educational, or promotional purpose that AHRQ deems appropriate.

I hereby waive any right to inspect and approve the rough cut, draft, promotional, or finished products.

AHRQ will not provide royalties, compensation, or residuals for this use.

Name:   _________________________________________________________________

Address:  _______________________________________________________________

Phone Number:  ____________________________ Email:  _______________________

Signature (if over 18):  ______________________________________________________

Date:  __________________

Signature of Parent or Guardian of a minor: ______________________________

Date:  __________________

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Meeting Participant Releases

A Release for Meeting Participants is used when recording large meetings for rebroadcast when certain people will be speaking and identified. This includes members of the audience who ask questions. If those audience members are not known before they speak, every effort should be made to have them sign the meeting participant release before they leave the room.

Meeting Participant Release Form (Microsoft Word, 20 KB).

Meeting Participant Release Form

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, film, photograph, or other medium.
  2. Use my name, likeness, voice, 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:_____________________________________________________________________

In addition, this language should be posted on the door to the meeting, as well as on a sign-in sheet for the general audience:

This meeting is being videotaped [or audiotaped] for public exhibition. The production will include video images [or audio recordings] of the audience. Anyone not wishing to appear in the production is hereby advised against attending this meeting. By entering the premises, you are granting permission to be included in the production for all purposes and in all media. Thank you.

The audience sign-in sheet is to be sure that audience members acknowledge their awareness of the recording and that their images/voices may be recorded. You will not need an additional release unless they become a participant.

Meeting Participant Sign-in Sheet (Microsoft Word, 20 KB).

Meeting Participant Sign-In Sheet

[Note: This information also should be posted on the meeting room door(s).]

This meeting is being videotaped [or audiotaped] for public exhibition. The production will include video images [or audio recordings] of the audience. Anyone not wishing to appear in the production is hereby advised against attending this meeting. By entering the premises, you are granting permission to be included in the production for all purposes and in all media.

Thank you.

If you agree to the statement above, please print and sign your name and add the date below.

Print Name, Then Sign Date
   
   
   
   
   
   
   
   
   
   
   
   

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Talent Release for Actors

This form is a sample of what to use when you hire people who are not government employees as narrators, actors, or extras for a scripted video. This includes any paid and unpaid talent, if you think their participation will be recognizable in the final video. It also includes extras who happen to be employees working at your location (such as a hospital or office). It does not matter if, ultimately, their image is not used; you should protect the production (and the government’s property) by getting the release signed.

Talent Release Form (Microsoft Word, 21 KB)

If you already have a form that includes the elements in the talent release form, you can use it. If your actors are being paid for their work, the specific amount of compensation should be specified. If they are represented by a talent agency, union, or other organization, the representative’s contract may substitute for this release as long as it states that the actors are being paid for “worldwide rights in perpetuity.” If not cost-prohibitive, negotiate a talent agreement that will not expire.

You also can modify this release for audio production or still photography as long as you specify the type of production and modify the language appropriately.

TALENT RELEASE FORM

Agency for Healthcare Research Quality (AHRQ)
U.S. Department of Health and Human Services

I hereby grant to the Agency for Healthcare Research Quality (“AHRQ”) and [list any other offices or partners if working under a partnership] their assignees, successors, and those acting in pursuant to their authority, permission and worldwide rights in perpetuity to:

  1. Record my participation and appearance on videotape, audiotape, file, photograph, or other medium.
  2. Use my name, likeness, voice, CV, and biographical material [or that of the minor child in my control] in connection with or promotion of this production. In addition, nothing shall require AHRQ to use my name, likeness, voice [or that of my minor child] in any manner.
  3. Exhibit, broadcast, cablecast, 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 that AHRQ, its assignees, successors, and those acting pursuant to its authority, deem appropriate.
  4. (a) No royalties or residuals will be paid to me for my participation. [If providing nonmonetary compensation] I will receive nonmonetary or promotional consideration only.

    OR

    (b) No royalties or residuals will be paid to me, but I will be paid a fee of $XX for my participation.
  5. I hereby waive any right to inspect and approve the rough cut, promotional, or finished product.

I warrant that I am over the age of 18 years² and that I am free to enter into this Agreement [on behalf of my minor child].

[If a minor is used, this statement should be amended and additional signature lines should be added for a parent or guardian. Unless the participating minor cannot write, the participant also must sign the release form.]

By signing this release, I hereby agree to hold AHRQ harmless from and against any and all claims, liabilities, losses, or damages that may arise from my participation in this production.

Signature:_____________________________________________________________________

Printed Name:__________________________________________________________________

Address:______________________________________________________________________

Phone Number: (area code) xxx-xxxx     Email:_______________________________________

Date signed:___________________________________________________________________

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Location Release

This release is used to obtain official permission to record at a particular location. This is not the same thing as obtaining a government permit to record on government property, in cases when a permit(s) is required.

Location Release for [LOCATION]

For [Purpose or Name of Event]

The undersigned (“Administrator”) hereby grants to the Agency for Healthcare Research and Quality (AHRQ) and [Contractor] (collectively known as the “Producer”) the permission, right, and license to photograph, record, audiotape, and videotape the (“Premises”) [may need to be more specific] located at [complete address with ZIP code] for a media production (“Project”) that is tentatively titled [INSERT NAME].

Under the terms of this agreement, Producer is permitted to occupy and use the Premises for the period beginning [date and time period if relevant]. During this period, Producer may place all necessary sets and equipment on the Premises, including possibly blocking some doors (but not emergency exits), and running extension cords through the hallways.

Producer agrees to exercise reasonable care to protect the Premises from damage and to leave the Premises in the condition in which they were found. Producer warrants that it carries liability insurance that covers the presence of production employees and the operation of equipment on the Premises. Producer further warrants that it will hold the Administrator harmless from, and indemnify against, any injury to any person(s) that may occur on the Premises as a result of Producer’s activities.

Under the terms of this license, any pictures or recordings taken of the Premises, including those of any signs that may appear on the property, will become the sole and exclusive property of AHRQ in perpetuity. AHRQ will retain the full and irrevocable right to produce, copy, distribute, exhibit, and transmit the pictures and recordings by means of broadcast/cablecast, videotape, DVD, print, Internet, or any other electronic or mechanical method or medium now known or hereafter invented. The Administrator’s successors and assigns shall have no right to bring legal action against Producer for any use of the pictures or recordings.

Administrator represents and warrants that Administrator has the full authorization to grant Producer the license and other rights granted herein. Administrator understands that Producer is relying on Administrator’s consent and agreement herein for Producer to proceed with preparation, production, and exhibition of the Project. Administrator agrees to indemnify and hold harmless the Producer, Producer’s employees, agents, assigns, and successors from and against any loss, damage, cost, and liability resulting from any breach by Administrator of any of the terms hereof.

[If there is any fee or other compensation being paid to the location for use of their Premises, it should be spelled out here.]

Nothing in this agreement shall obligate Producer to use the Premises for filming or recording or to include material shot on the Premises in the Project. Producer may at any time cancel this agreement by notifying Administrator in writing of its intent not to use the Premises. [Again, if there’s any compensation due, there should be something here spelling out what happens in case of cancellation.]

AGREED AND ACCEPTED:

Administrator:

Printed Name and Title: ___________________________________________________

Signature: ______________________________________________________________

Date: __________________________________________________________________

For Producer:

Printed Name and Title: ___________________________________________________

Company Name: _________________________________________________________

Signature: ______________________________________________________________

Date: __________________________________________________________________

Company Address: _______________________________________________________

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Licensing Agreement

(Name of organization/individual) holds copyright to the (name of item) and conveys a nonexclusive, irrevocable, (worldwide) royalty-free license to the Agency for Healthcare Research and Quality (AHRQ) to use and reproduce the material (specify form and quantities—print and/or electronic, number of copies or unlimited quantities).

AHRQ agrees to include a notice of copyright on all materials that it provides and distributes. AHRQ may post (name of the item) in its entirety or a summary on its website. [Add this sentence if necessary: AHRQ will provide users with information regarding (name of organization/individual) for potential purchase of print copies of (name of item).] (Name of organization/individual) allows AHRQ to distribute the material and to advertise/promote its availability as described in this agreement.

The copyright holder allows AHRQ to grant permission to outside organizations to use this material without a fee, under the condition that the outside organization does not change or sell the material.

[If a third party holds the copyright, the following sentence may be included: AHRQ acknowledges that all copyright terms are in accordance with the copyright agreement signed and dated ______________ for (name of the item) and (name of the third party).]

The use of (name of item) under license by AHRQ or its agents or representatives is acceptable to AHRQ and the (name of organization/individual).

Signatures:

AHRQ Representative ____________________________ Date _______________

Copyright Holder ____________________________ Date _______________

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HHS Presentation Agreement

Representations:  I hereby represent to (Conference Sponsor) that, with respect to the presentation titled ________________________________________________________,

  • I have prepared the presentation as part of my official duties as a Department of Health and Human Services (HHS) employee.
  • I have obtained permission from copyright owners of any excerpts from copyrighted works that are included in the presentation and have credited the sources in the presentation.

Copyright. 17 U.S.C § 105 states that copyright protection is not available in the United States for any work of the U.S. Government. Since the presentation was done as part of my official duties as an HHS employee, the presentation is a work of the U. S. Government and as such is in the public domain.

I hereby permit the conference sponsor to record on film, tape, digital storage medium, or otherwise, the above presentation for any and all uses, except that the conference sponsor may not give the appearance that HHS endorses any products, services, or policies of the conference sponsor or any other non-Federal entity. The conference sponsor shall not compensate me for work done as part of my official duties. 

This agreement shall be governed and construed in accordance with Federal law as interpreted by the Federal courts in the District of Columbia.

 

Signature ________________________________________   Date ____________________________

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Page last reviewed June 2019
Page originally created February 2013
Internet Citation: Appendix 1-A. Permission Forms and Licensing Agreement. Content last reviewed June 2019. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/research/publications/pubcomguide/pcguide1apa.html
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