CONSENT FOR PRODUCTION AND USE OF VERBAL OR WRITTEN STATEMENTS, PHOTOGRAPHS,
DIGITAL IMAGES, AND/OR VIDEO OR AUDIO RECORDINGS BY VA
Name of individual whose statement,
likeness, or voice is requested
NOTE: The execution of this form does not authorize production or use of materials except as specified below.
The specified material may be produced and used by VA for authorized purposes identified below, such as
education of VA personnel, research activities, or promotional efforts. It may also be disclosed outside VA as
permitted by law and as noted below. If the material is part of a VA system of records, it may be disclosed
outside VA as stated in the “Routine Uses” in the "VA Privacy Act Systems of Records" published in the Federal
Register.
The purpose of this form is to document your consent to the Department of Veterans Affairs' (VA) request to
obtain, produce, and/or use a verbal or written statement or a photograph, digital image, and/or video or audio
recording containing your likeness or voice. By signing this form, you are authorizing the production or use only
as specified below.
You are NOT REQUIRED TO CONSENT TO VA's REQUEST to obtain, produce, and/or use your statement,
likeness, or voice. Your decision to consent or refuse will not affect your access to any present or future VA
benefits for which you are eligible.
You may rescind your consent at any time prior to or during production of a photograph, digital image, or video
or audio recording, or before or during your provision of a verbal or written statement. You may rescind your
consent after production is complete if the burden on VA of complying with that request is not unreasonable
considering the financial and administrative costs, the ease of compliance, and the number of parties involved.
The photograph, digital image, and/or video or audio recording will be produced while I am (describe the activity or
situation) (To Be Completed by the Department of Veteran Affairs, if applicable)
As a patient, caregiver, visitor or staff member at the Audie Murphy VA Medical Center
Check at least one of the following (to be completed by VA)
I hereby voluntarily and without compensation authorize
Audie Murphy VA Medical Center
Name of Facility
to produce a photograph, digital image, and/or video or audio recording of me (or of the above named individual if the
individual is legally unable to give consent).
Audie Murphy VA Medical Center
I hereby voluntarily and without compensation authorize
Name of Facility
to obtain or use a verbal or written statement from me ( or the of the above named individual if the individual is legally
unable to give consent).
VA FORM
10-3203
NOV 2014
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