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CHFM Oral History COVID-19 Interview Form

Thank you for agreeing to participate in an oral history interview. This interview will focus on your experience with COVID-19 in family medicine. The interview will take on average 15-30 minutes to complete. Please answer the following questions, and CHFM staff will reach out to schedule the interview at a date and time that works best for you. Any questions please contact Crystal Bauer at cbauer@aafp.org.
1.What is your first name?(Required.)
2.What is your last name?(Required.)
3.What is your preferred name if different from above?
4.At what email address would you like to be contacted?(Required.)
5.What is your AAFP Member ID?(Required.)
6.Please select your current career focus:(Required.)
7.Please select the best time of day to schedule the interview:(Required.)
8.Please select the best days of the week to conduct the interview in the next month:(Required.)
9.This confirms my agreement with you, the Center for the History of Family Medicine, to participate in an oral history recording interview ("the Interview").I authorize you to photograph and record on videotape, film, audiotape, or in any other manner or media now or hereafter known, my appearance in the Interview. I acknowledge that all rights in and to my contribution in the Interview, and any reproductions thereof belong to the Center for the History of Family Medicine or its administering organization, the American Academy of Family Physicians Foundation.I hereby convey and transfer to the Center for the History of Family Medicine, its successors, heirs and assigns, all rights, title, and interest in copyright which I may have or be deemed to have in said work and more particularly the exclusive rights of reproduction, distribution, preparation of derivative works, public performance and display. I understand that, only if I so designate and place restrictions on access to the Interview, only authorized persons, including employees of the Center for the History of Family Medicine, will have full and unrestricted use of the unedited version of the recordings. I understand that I will receive one copy of the oral history recording and one copy of the transcript that are produced from the recording if I so request to receive said copies. I also understand that these copies will not be immediately available and will be given/sent to me when they are completed.
(Required.)
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