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A. Personal Information (This information will be used solely for internal administrative purposes, and for contacting you in the future in the event that further notification and/or consents are necessary.)

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B. Recording Details (Please be as specific as possible.)

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C. Permitted Uses (I consent to the following uses, except where limited in section D.)
• Administrative: Made available or used within мÓÆÂÁùºÏ²Ê¿ª½±Ö±²¥. Example uses: ID cards, printed directories or handbooks, intranets or private websites.
• Publications: Made available or used externally on a not-for-profit basis. Example uses: marketing and promotional material (brochures, DVDs, videos, websites), annual reports, media releases, magazine articles.
• Internal Education: Made available or used for educational purposes (including lectures, workshops, tutorials, lab or clinical skills demonstrations, grand round presentations) within мÓÆÂÁùºÏ²Ê¿ª½±Ö±²¥. Example uses: tutorial case exhibits, lecture handouts, DVDs or videotapes on library reserve, internal media or learning objective libraries.
• External Education: Made available or used for educational purposes external to мÓÆÂÁùºÏ²Ê¿ª½±Ö±²¥ on a not-for-profit basis. Example uses: external media or learning object libraries, journal articles, international projects.

D. Other limitations on Use (Please list other limitations, such as time limits on use, in detail below)