Disaster Response Facial Consent Form
Use this form to provide facial image consent and sharing preferences for disaster-response identification and support. No emojis, no title variations, and no claims of medical or HIPAA compliance.
Identity and Contact Information
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Please Select
Phone
Email
Image Details and Capture Context
Date of Image Capture
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Disaster Event or Response Context
*
Location Where Image Was Taken
*
Type of Image Submitted
*
Live photo
Printed photo
Digital file
Other
Release Preferences and Restrictions
Permitted uses for this image
*
Identification
Internal response coordination
Reunification support
Public communication
Other
May this image be used for identification purposes?
*
Yes
No
May this image be shared for internal response coordination and reunification support?
*
Yes
No
Use restrictions or special instructions
Submit
Should be Empty: