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This sample is a template from which a video recording release form can be developed. The language does not have to be repeated verbatim. THE CONSENT AGREEMENT SHOULD BE WRITTEN IN TERMS UNDERSTANDABLE TO THE SUBJECT (avoid or define technical terminology, adjust for educational background and ages, provide translations in other languages when subjects do not understand English).

For research projects that involve video recording, the video recording release form must be attached to the written consent form. If the investigator anticipates use of the recordings beyond the scope of the initial research project, the written consent form must indicate (a) who will view the recordings; (b) for what purpose(s); (c) when the recordings will be erased or destroyed.

I have received an adequate description of the purpose and procedures for video recording sessions during the course of the proposed research study. I give my consent to be video recorded [If children will be video recorded, use the following: "I give my consent to allow _________ (child's name) to be video recorded..."] during participation in the study, and for those video recordings to be viewed by persons involved in the study, as well as for other professional purposes [clarify purposes] as described to me. I understand that all information will be kept confidential and will be reported in an anonymous fashion, and that the video recordings will be erased after the study has been completed [or a specified period of time, e.g., 7 years, etc.]. I further understand that I may withdraw my consent at any time.

Print Name_____________________________________________

Signature of parent/legal guardian___________________________Date_________
(if subject is a child)

Print Name____________________________________________

Signature of participant______________________________ Date_________