Guidelines for National Consent Form for

Publicity/Filming/Photography

Document Type

Policy Document developed by

Valerie Kavanagh

Revision number

0 Document approved by

Kirsten Connolly

Approval Date

- Responsibility for implementation

All HSE Communications Staff

Revision Date

2yrs Responsibility for review and audit

Valerie Kavanagh

Draft or Final document

Draft version 1

Publicity/Filming/Photography Consent Form: For office use only: Insert name and caption of photo/ dvd/audio production / film clip (include where photo/dvd/audio production/ film clip was taken) ….…………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… Name of client/resident/patient ______________________________________________ This photograph/film/audio production will only be used for Health Service Executive purposes that may include: • Information literature/publications, including print media, posters, leaflets, booklets, HSE annual

report etc.

• Videos/dvds/audio productions • Website/intranet/extranet/social media • Recruitment information/ advertisements • HSE Health Matters

It is the intention of the Health Service Executive Communications Division that the photos/dvd/audio production are used appropriately and sensitively. Please indicate your consent on your own behalf (and on behalf of your child if applicable) for this filming/photography/publicity and that you fully understand the reason for the photography/filming/audio by signing below. You also give permission for the image and likeness of you/your child to be distributed to national, regional and local print and online media and medical trade magazines. I agree that no fee will be made to me or my child in payment for participation in this photocall/filming/audio session or in relation to images/film/audio carried in any of the platforms described above. Name…………………………………………………………………………………………..…… Address…………………………………………………………………………………………….. ……………………………………………………………………………………………………… Tel/Mobile…..………………………………….Email……………………………………………Date..…………… Please return a copy of this form to Communications Division, Health Service Executive. Address…………………………………………………………………………………………….. Tel/Mobile…..………………………………….Email……………………………………………