Va Form 10002 - Consent For Use Of Written Or Verbal Statement, Picture And/or Voice

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CONSENT OF (Name)

CONSENT FOR USE OF WRITTEN OR

VERBAL STATEMENT, PICTURE AND/OR VOICE

NOTE: The information requested on this form is solicited under the authority of title 38, United States Code. The execution of this form does not

authorize disclosure of the materials specified below except for the purpose(s) stated. The specified material may be used within the VA for

authorized purposes, such as for education of VA personnel or for VA research activities. It may also be disclosed outside the VA as permitted by

law. If the material is part of a VA system of records, it may be disclosed outside the VA as stated in the 'Routine Uses' in the "VA Privacy Act

Systems of Records" published in the Federal Register. A copy of the 'Routine Uses' is available upon request to the administrative office of the VA

facility involved. You do not have to provide consent to have your verbal and/or written statement(s), picture(s) or voice recorded, or used. Your

refusal to grant your consent will have no effect on any VA benefits to which you may be entitled.

I hereby voluntarily and without compensation authorize verbal and/or written statement(s), pictures and/or voice recording(s)

to be made of me (or of the above-named individual if the individual is legally unable to give consent) by (specify the name of the VA facility,

newspaper, magazine, television station, etc.).

While I am (describe the activity, if any, to be photographed or recorded).

I authorize disclosure of the verbal and/or written statement(s), picture and/or voice recording to (specify name and address of the

organization, agency, or individual(s) to who the release is to be made).

I have read and understand the foregoing and I consent to the use of my verbal and/or written statement(s), picture(s) and/or voice as specified for the

above-described purpose(s). I further understand that no royalty, fee or other compensation of any character shall become payable to me by the

United States for such use. I understand that consent to use my verbal and/or written statement(s), picture(s), video and/or voice recording(s) is

voluntary and my refusal to grant consent will have no effect on any VA benefits to which I may be entitled. I further understand that I may at any

time exercise the right to cease the use of my verbal and/or written statement(s), filmed, photographed or recorded, and may rescind my consent for

up to a reasonable time before the verbal and/or written statement(s), picture, video or voice recording is used.

SIGNATURE OF INDIVIDUAL OR OTHER LEGALLY AUTHORIZED PERSON

DATE

PERMISSION OBTAINED BY (NAME - TITLE - ADDRESS)

DATE

SIGNATURE OF INTERVIEWER OR INDIVIDUAL OBTAINING CONSENT

DATE

INDIVIDUAL'S NAME AND ADDRESS