VA Form 10-3203 Consent for Production and Use of Verbal or Written Statements, Photographs, Digital Images, and/Or Video or Audio Recordings by Va

VA Form 10-3203 is a United States Department of Veterans Affairs form also known as the "Consent For Production And Use Of Verbal Or Written Statements, Photographs, Digital Images, And/or Video Or Audio Recordings By Va".

The form was last revised on November 1, 2014 - download an up-to-date fillable PDF VA Form 10-3203 down below or find it on the Veterans Affairs Forms website.

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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
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
I consent to allowing VA to record and use a verbal or written statement, or produce and use photographs, digital images,
and video or audio recording for the purpose(s) identified below:
This product will be used: (NOTE: At least one of these boxes must be checked as well as a purpose described below)
(to be completed by VA)
Externally ( shared outside VA)
Internally (stay within VA)
Please check the applicable purpose(s) (to be completed by VA)
Promotional Efforts:
Internal Publication (only VA)
External publication (publicly available)
Other (Specify):
Research Activities:
Study
Education Purposes:
Presentation
Conference
Publication in a Journal
Training
Other (Specify):
VA ONLY Use:
Performance Improvement
Quality Improvement
Health Care Operations
Other (Specify):
All of the Above
NOTE: Do not sign this form unless one or more of the boxes above has been checked.
I have read and understand the foregoing, and I consent to the use of a verbal or written statement from me, and/or of my likeness
and/or voice as specified for the above-described purpose(s). I understand that no royalty, fee, or other compensation of any kind will
be made to me by the United States for such use. I understand that consent to obtain, produce, and/or use a verbal or written
statement, photograph, digital image, and video or audio recording containing my likeness or voice is voluntary, and my refusal will not
adversely affect my access to any present or future VA benefits for which I am eligible. I further understand that I may, at any time,
rescind my consent prior to or during production of a photograph, digital image, or video or audio recording. I also understand that I
may rescind my 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.
Print Full Name (First and Last Name)
Date
Signature
Consent Obtained By (TO BE COMPLETED BY VA)
Print Employee Full Name
Date
Title
Signature of Person Obtaining Consent (TO BE COMPLETED BY VA)
Signature
IMPORTANT: If VA is providing or releasing any patient health or demographic information with the verbal or written statement,
photograph, digital image, or video or audio recording, VA Form 10-5345, Request for and Authorization to Release Medical Records or
Health Information, is required prior to the release of such data to any source outside VA.
PAGE 2
VA FORM
10-3203
NOV 2014

Download VA Form 10-3203 Consent for Production and Use of Verbal or Written Statements, Photographs, Digital Images, and/Or Video or Audio Recordings by Va

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