Form Ds 6017 Media Access Request And Agreement - California Department Of Developmental Services
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1
2State of California—Health and Human Services Agency
Department of Developmental Services
Media Access Request and Agreement
Reset Form
DS 6017 (Rev 02/2016)
This form is for media to request access to the Department of Developmental Services’ (Department) Developmental Centers
and State-Operated Community Facilities. Please submit this form to the Communications Director at the Department of
Developmental Services Office of Communications at 1600 Ninth Street, Room 322, MS 3-10, Sacramento, CA 95814, or Fax
to: (916) 654-1913. Please call (916) 654-18
for the email address.
As a condition of and in consideration for the Department’s grant of access to its facilities for photographing, filming,
recording, interviewing or other media related activities, if granted access, I understand and agree to comply with the
privacy rules of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the California Confidentiality
of Medical Information Act, the California Welfare and Institutions Code and all other applicable state and federal laws,
to safeguard patient privacy. Media access to Department Developmental Centers and State-Operated Community
Facilities requires prior authorization by the Department. Please allow a minimum of 15 working days prior to the
requested entry date.
Requestor: _________________________________________________ Submission Date: ___________________________
Office Phone: ______________________ Cell Phone: ____________________ FAX: _______________________________
Contact E-mail address: ________________________________________________________________________________
Employer/Entity: ______________________________________________________________________________________
Location(s) requested: _________________________________________________________________________________
Area(s) within facility: __________________________________________________________________________________
Briefly describe purpose/objective(s) of access:
Desired and alternative access dates and times
(Provide as many options as possible, including dates and times.):
Expected Number of people (
.):
List names and function if known
Activity intended (
:
Tour of facility
Photograph
Digital
Video
Film
Television
Check all that apply)
Interview-unrecorded
Interview-audio recording
Interview- video/film recording
Other (
): ____________________________________________________________________________________
describe
Intended subject(s): __________________________________________________________________________________
Name(s) of person(s) to be interviewed if applicable _______________________________________________________
I agree that I shall not interview, audio record, photograph, videotape, film, or otherwise record the likeness of any individual,
until or unless the individual or person authorized to consent has signed a written consent form.
I have been informed that the Department of Developmental Services has legal and ethical responsibilities to safeguard the
privacy of its consumer and their families and to protect the confidentiality of protected health information. I understand and
agree that if I am granted authorization to engage in photographing, filming, recording, interviewing or other media related
activities, I shall uphold these legal and ethical responsibilities.
Your Signature
Date
_____________________________________________
___________________________________
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