SOP 102.01-att-1: Interview Request Form (Attachment 1)

SOP 102.01
Attachment 1

7/14/22

_GEORGIA DEPARTMENT OF CORRECTIONS_
# INTERVIEW REQUEST FORM

I, ___________________________________ / ________________________________, herby grant permission
(Offender Name/GDC Number) (Employee Name/Number)

to the Georgia Department of Corrections and _____________________________________________ to make use of
(Publication, Station, News Agency)
my name, comments, still or motion pictures, voice recordings or videotape of me for any legitimate purposes including
publication in news media and for professional and institutional purposes.

I hereby release and hold harmless the GDC, its agents and servants from any and all claims for damage for libel,
slander, invasion of the right of privacy or any other claim based on the use of said material.

The above consent is given by me freely and voluntarily without any promises, threats, or duress.

(Staff Signature/Number) (Date)

(Offender Signature/ GDC Number) (Date)

(Witness Signature) (Print Name, Title)

Notice: Offenders who are a party to any pending or anticipated legal proceeding are advised to notify their
attorneys prior to conducting a media interview.

DENIAL OF INTERVIEW REQUEST

I decline to be interviewed by the media representative from _________________________________ on this date.

(Offender Signature/GDC Number) (Date)

Retention Schedule: Upon completion of request by offender, the form is to be retained in the offender’s institutional
file and held according to the retention schedule for offender’s institutional file.

Upon completion by an employee, the form will be retained in the Public Affairs Office for three (3) years.