Form 1 2009 Flu Prevention PSA Contest Form

Form Approved

OMB Number 0990-XXXX

Expiration Date: 01/31/2010

 

2009 Flu Prevention PSA Contest Form

Your Email:

(This is how we will contact winners)

Video title as Submitted:

(Give your PSA a unique title – not just “Flu prevention PSA”)

Date Posted to YouTube:

(Deadline for posting your video and this form is 11:59pm EDT on August 17^th, 2009)

Your Video’s YouTube URL:

(We need this in case videos have the same name)

By clicking the submit button, I certify that I am the creator of the video titled above; have read and agree to the contest rules (link); am over 14 years of age and, if under 18 years of age, have parent/guardian permission to enter this contest; neither I nor any member of my immediate family is an HHS employee, contractor or grantee, and that I grant HHS a royalty-free license to copy, distribute, modify, display, and perform publicly and otherwise use, and authorize others to use, your video for any educational purpose throughout the world and in any media.

 

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information collection is estimated to average (hours)/ (minutes) per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201 Attention: PRA Reports Clearance Officer.