UNIVERSITY OF CALIFORNIA, BERKELEY



UNIVERSITY OF CALIFORNIA, BERKELEY

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Appendix Vc

Research Media (Photographic, Audio, and/or Video) Records Release Form

[THIS FORM SHOULD BE ADAPTED TO A PARTICULAR STUDY AS APPROPRIATE]

As part of this project we will make photographic, audio, and/or video recordings of you while you participate in the research. Please indicate below by initialing what uses of these records you consent to. This is completely up to you. We will only use the records in the way(s) 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

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I certify that I am 18 years or older. I have read this release form and I agree to take part in this research.

| | | |

|Signature | |Date |

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|SANTA BARBARA ( SANTA CRUZ |

|BERKELEY ( DAVIS ( IRVINE ( LOS ANGELES ( RIVERSIDE ( SAN DIEGO ( SAN FRANCISCO |

| |

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Rowilma del Castillo, Manager

Hearst Memorial Gym, Suite 2

Berkeley, CA 94720

Tel; (510) 642-4159

rowilma@haas.berkeley.edu

Mailing Address:

EXPERIMENTAL SOCIAL SCIENCE LABORATORY

Social Science Matrix

Hearst Memorial Gym, Suite 2

Berkeley, CA 94720

Professor Don Moore, Director

Haas School of Business

F565 Haas School of Business

Berkeley, CA 94720-1900

Tel: (510) 642-1059

dm@berkeley.edu

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