[Organization Name]
[Organization Address]
[City, State, ZIP Code]
[Email Address]
[Phone Number]
Date: [Date]
Subject: Biometric Consent Form
This Biometric Consent Form is provided by:
Organization Name: [Organization Name]
Contact Person or Department: [Name / HR / Privacy Team / Compliance Department]
Address: [Address]
Phone Number: [Phone Number]
Email Address: [Email Address]
The individual providing consent is:
Full Name: [Full Name]
Address: [Street Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]
Email Address: [Email Address]
Employee ID, Customer ID, or Other Reference, if applicable: [Reference Number]
3. Biometric Data Covered
The organization may collect, capture, receive, record, convert, store, or otherwise use the following biometric identifier or biometric information:
☐ Fingerprint
☐ Face scan or face geometry
☐ Hand geometry
☐ Voiceprint
☐ Retina or iris scan
☐ Other biometric data: [Describe]
This form applies only to the biometric data identified above unless a new written authorization is obtained where required.
4. Purpose of Collection and Use
The biometric data described above may be collected, stored, and used for the following purpose or purposes:
☐ Identity verification
☐ Timekeeping or attendance tracking
☐ Access control or building entry
☐ Device or system login
☐ Fraud prevention or account security
☐ Customer authentication
☐ Other purpose: [Describe]
Additional explanation of the intended use:
[Describe how and why the biometric data will be used]
5. Retention and Destruction
The organization states that the biometric data will be retained only for as long as reasonably necessary for the purpose stated above, or for any shorter or longer period required by applicable law, contract, litigation hold, or regulatory obligation.
Estimated retention period or event for destruction:
[Insert time period, event, or policy reference]
Method or policy for destruction, deletion, or permanent removal:
[Describe or refer to retention/destruction policy]
6. Disclosure and Sharing
The organization may disclose or allow access to the biometric data only as follows:
☐ Internal personnel with a business need to know
☐ Service providers or vendors supporting the stated purpose
☐ Affiliates or related entities, if applicable
☐ As required by law, court order, warrant, or subpoena
☐ Other permitted disclosure: [Describe]
The biometric data will not be sold, leased, traded, or otherwise disclosed except as stated in this form, in the organization’s policy, or as otherwise permitted or required by applicable law.
7. Security and Protection
The organization states that it will use reasonable administrative, technical, and physical safeguards to protect biometric data from unauthorized access, use, disclosure, alteration, or loss.
These safeguards may include:
-
restricted access;
-
encryption or secure storage;
-
vendor controls;
-
role-based permissions; and
-
deletion or destruction procedures when no longer needed.
restricted access;
encryption or secure storage;
vendor controls;
role-based permissions; and
deletion or destruction procedures when no longer needed.
8. Voluntary Consent
By signing below, I acknowledge and agree that:
-
I have been informed that biometric data identified in this form may be collected, stored, and used;
-
I understand the purpose for which the biometric data is being collected and used;
-
I understand the expected retention period or destruction standard described above;
-
I understand the disclosure terms stated in this form;
-
I have had the opportunity to ask questions about this form; and
-
I voluntarily consent to the collection, storage, use, and permitted disclosure of my biometric data as described in this form.
I have been informed that biometric data identified in this form may be collected, stored, and used;
I understand the purpose for which the biometric data is being collected and used;
I understand the expected retention period or destruction standard described above;
I understand the disclosure terms stated in this form;
I have had the opportunity to ask questions about this form; and
I voluntarily consent to the collection, storage, use, and permitted disclosure of my biometric data as described in this form.
9. Withdrawal of Consent
If permitted by applicable law, contract, or the operational purpose involved, I may request withdrawal of this consent by submitting a written request to:
[Name / Department / Email / Address]
The organization may continue to retain or use biometric data to the extent required to complete an authorized process, comply with law, maintain security, preserve records, or fulfill another permitted obligation.
10. No Transfer of Other Rights
This form only addresses biometric consent. It does not change any other employment, service, account, privacy, contract, or legal rights except as expressly stated here.
Any additional terms or limitations are as follows:
[Insert details or write “None”]
11. Signature of Individual
I have read this Biometric Consent Form and agree to its terms.
Signature: __________________________
Printed Name: [Full Name]
Date: [Date]
12. Parent or Guardian Consent
Complete this section if the individual is a minor or if consent must be given by a legally authorized representative.
Name of Parent / Guardian / Authorized Representative: [Full Name]
Relationship to Individual: [Relationship]
I represent that I am authorized to provide consent on behalf of the individual identified in this form.
13. Organization Acknowledgment
Received by:
Signature: __________________________
Name: [Name]
Title: [Title]
Organization: [Organization Name]
Date: [Date]
14. Optional Policy Reference
Related biometric policy, privacy notice, retention schedule, or vendor notice:
[Insert document title, date, or reference]
15. Optional Attachment List
☐ Biometric policy
☐ Retention and destruction schedule
☐ Vendor disclosure notice
☐ Privacy notice
☐ Other: [Describe]
