SAMPLE CONSENT for USE OF PHOTO, AUDIO, or VIDEO RECORDINGS
[ADAPT AS APPROPRIATE – ALSO SEE INSTRUCTIONS BELOW RE LANGUAGE TO INCLUDE IN THE MAIN CONSENT FORM]
University of Chicago
Research Media Records Release Form
As part of this project we will make photographic, audio, and/or video recordings of you while
you participate in the research. We are asking your permission to share those photographs/recordings with people who are not part of this research team, in the ways described below. Please indicate below by initialing what uses of these records you consent to. This is completely up to you. We will only use the records in the way(s) that you agree to. In any use of these records, your name will not be included.
1. The photographs/recordings can be included in publications and presentations about this research study that are seen by other researchers and by the general public.
Photo ______Audio ______Video ______
initials initials initials
2. The photographs/recordings can be stored indefinitely in an archive/stimulus set that will be available to other researchers for use in their research studies, including showing the photographs/recordings to participants in other research studies.
Photo ______Audio ______Video ______
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3. The records can be shown in classrooms to students.
Photo ______Audio ______Video ______
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4. The records can be used on television and radio.
Photo ______Audio ______Video ______
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I have read this form and give my consent for use of the records as indicated above.
Signature ______Date ______
CONSENT FORM REFERENCE TO MEDIA RECORDS RELEASE FORM
When using a separate Media Records Release Form for photographs, audio, and/or video recordings made as part of the research, the main study consent form should include a brief reference/ explanation for this, such as:
"I may want to use some of the photographs, audio, or video recordings of you in public presentations related to the research. There is a Media Records Release Form attached that outlines several possible uses and asks for your specific consent to use these items in each way. If you agree to allow these items to be used after this research study is over, please read, initial, and sign the Media Records Release Form in addition to this consent form. I will not use any photographs, recordings, or other identifiable information about you in any future presentation without your consent."
Please note: A Media Records Release Form is not needed if only the lead investigator and other research team members will have access to the recorded materials for analysis, or the recorded materials will only be shared with a transcriptionist. In such cases, the researcher's intent to photograph or record should be disclosed in the main study consent form, along with information about restricted use and access of the photos/recordings, as well as when they will be destroyed and/or how long they will be retained.