requested permission form

[Susan Ervin-Tripp]

I have used this form in the United States but have been given
waivers for use in some countries where asking for a signature implies
you may be proposing a serious risk. The Human Subjects Committee
is willing to make such distinctions.

Susan Ervin-Tripp

******************************************************
[PLEASE FEEL FREE TO EDIT THIS FORM TO SUIT YOUR PARTICULAR RESEARCH NEEDS.
THE FIRST LINE MAY NEED TO BE REVISED IF THE SUBJECT OF THE RECORDING IS
SOMEONE OTHER THAN THE PERSON CONSENTING.]

                     (To Be Presented on Letterhead)

PHOTOGRAPHIC, AUDIO, AND/OR VIDEO RECORDS RELEASE CONSENT FORM

As part of this project we have made a photographic, audio, and/or video
recording of you while you participated in the research. We would like you
to indicate below what uses of these records you are willing to consent to.
This is completely up to you. We will only use the records in ways that you
agree to. In any use of these records, your name will not be identified.

1. The records can be studied by the research team for use in the research
project.

Photo __________ Audio __________ Video __________

initials initials initials

2. The records can be shown to subjects in other experiments.

Photo __________ Audio __________ Video __________

initials initials initials

3. The records can be used for scientific publications.

Photo __________ Audio __________ Video __________

initials initials initials

4. The records can be shown at meetings of scientists interested in the
study of ___________

Photo __________ Audio __________ Video __________

initials initials initials

5. The records can be shown in classrooms to students.

Photo __________ Audio __________ Video __________

initials initials initials

6. The records can be shown in public presentations to nonscientific groups.

Photo __________ Audio __________ Video __________

initials initials initials

7. The records can be used on television and radio.

Photo __________ Audio __________ Video __________

initials initials initials

I have read the above description and give my consent for the use of the
records as indicated above.

______________________________________ Date _________________

Signature ______________________________________ Date _________________

Signature of Guardian, if Applicable



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