UNC Employee Video Consent Form


Photography/Videography Release


Employee Consent and Release Form and Permission to Use Materials: Photographs, Video Recording, Audio Recordings, PowerPoint and/or Interviews

NOTE: The purpose of this consent form is to allow an employee to be photographed, video recorded, audio recorded, and/or interviewed in relation to his or her duties. If such photograph, videotape, recording and/or interview includes a patient, the patient or the patient’s authorized representative (if the patient is a minor or is not decisionally capable) MUST sign the Patient Photograph/Video and Information Release Authorization Form (MIM #739).
I authorize UNC Health Care System and The UNC Telehealth Program with the UNC Cancer Network to use and release a photograph, videotape, audio recording, or interview of me, in printed or electronic form, including via live streaming, for internal use by UNC Health Care (for example, on the intranet), and/or for the public media, including (but not limited to) newspapers, television, magazines, pamphlets, brochures, the internet, live internet streaming and recorded video for later viewing. I further understand and agree that this use and release may include identifying information, including name, job title, and employer.

I further understand that no patient may be photographed, videotaped, or audio recorded without authorization from the patient or, if the patient is a minor or is not decisionally capable, from his or her authorized representative (see PHOTOGRAPH/ VIDEO AND INFORMATION RELEASE AUTHORIZATION FORM, MIM #739).



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