Appendix 1-A. Copyright: Permission Forms and Licensing Agreement

AHRQ Publishing and Communications Guidelines

Sample Form for AHRQ Employees To Use To Obtain Permission To Use Copyrighted Materials in Journal Articles

Date:
As copyright owner, I hereby authorize (name of AHRQ employee), an employee of the Agency for Healthcare Research and Quality (AHRQ), to use the following material:

Name of particular chart, table, or other written material, with its current published location (name of article, name of journal, journal issue, and page number):  ______________________________________________________

This authorization is granted for a one-time use, in the following publication:

   (Full reference to paper, journal, etc.)

This authorization includes permission to reproduce and, if necessary, to redraw or modify the material for use in the article.

I understand that, because AHRQ is a Federal Government agency, the AHRQ employee's article is not subject to copyright.

I understand further that permission to reprint the AHRQ employee's journal article can be granted only by AHRQ, which will note that the article contains copyrighted material usable only with the permission of the copyright holder.

Full credit will be given to the publisher and authors. The proposed citation is:

Used by permission of copyright holder. (Same citation of material as above)

Permission is hereby granted:  _______________________________________________
                                                Printed name and title

                                              ___________________________________   ___________
                                                Signature                                                   Date

                                              ____________________________________  ___________
                                                Signature of AHRQ Requestor                      Date

 

Sample Generic Copyright Permission Form for AHRQ Publications

The undersigned hereby grant(s) permission to the Agency for Healthcare Research and Quality (AHRQ), hereinafter referred to as the "Publisher," located at 540 Gaither Road, Rockville, MD 20850, to use the material specified below in the publication titled ______________________________________________________________________

This permission is for AHRQ's use of ________________________ (text, graphics, figures, or photographs), copyrighted by me, for use in this publication and in materials using this publication or pertinent portions of it. These copyrighted items may be used in this publication, in both print and all electronic formats, including future editions thereof.

It is understood that the above grant of permission to AHRQ shall in no way restrict republication by me or with my consent, of the copyrighted item(s), in other works.

______________________________________________________________________

______________________________________________________________________

The following credit line should be used by AHRQ for each item that I hold copyright to (specify copyright year and names of holders):

______________________________________________________________________

Other provisions, if any:

______________________________________________________________________

If specified here, the requested rights are not controlled in their entirety by the undersigned, and the written consents of the following individua ls are attached or must be obtained:

______________________________________________________________________

______________________________________________________________________

One copy of this permission form shall be returned to the Publisher and one copy shall be retained by the Undersigned.

_______________________________         __________________

_______________________________         __________________
            Authorized Signatory                                     Date
_______________________________         __________________
            Authorized Signatory                                     Date

 

Sample Permission Form for Publication of Photographs

Production Date:

PLEASE PRINT:

NAME:  

ADDRESS:

TELEPHONE NUMBER: 

EMAIL ADDRESS: 

I hereby grant to the Agency for Healthcare Research and Quality (AHRQ) and its assignees, successors, and those acting in pursuant to their authority, (1) the right and permission to photograph and publish photographs of me, whether alone or with any other material, for informational or promotional purposes, in print or on Web sites; and (2) the right and permission to use and publish my name, biographical information, and/or other identifying material in conjunction with photographs of me.

This release covers use by AHRQ of my name and photograph(s), on Web sites or in other informational or promotional materials prepared by AHRQ, in association with publication of my research and/or promotion of that research, in perpetuity. I also waive any right to inspect or approve the draft or finished product.

No compensation, royalties, or residuals will be paid for this release.

I warrant that I am over the age of eighteen (18) years and that I am free to enter into this agreement.

SIGNATURE OF SUBJECT:

____________________________________________       DATE:_________________ 

SIGNATURE OF PARENT OR GUARDIAN OF A MINOR SUBJECT:

______________________________________________   DATE:________________

 

Sample AHRQ Release Form for Participation in an Audiovisual Production

Date of Participation:

I hereby authorize the Agency for Healthcare Research and Quality (AHRQ), assignees, successors, and those acting pursuant to its authority to:

  1. Record my participation and appearance on videotape, audiotape, photograph, or other medium.
  2. Use my name, likeness, voice, biographical information, and/or other identifying material in connection with or promotion of these recordings or photographs.
  3. Exhibit, broadcast, Webcast, store and forward, copy, edit, and/or distribute such recording in whole or in part without restriction or limitation, for any educational, commercial, or promotional purpose which AHRQ, assignees, successors, and those acting pursuant to its authority, deem appropriate, in perpetuity.

I hereby waive any right to inspect and approve the rough cut, draft, promotional, or finished product(s).

No royalties, compensation, or residuals will be paid for this use.

Name:   _________________________________________________________________

Address:  _______________________________________________________________

Phone Number:  ____________________________ Email:  _______________________

Signature of subject:  ______________________________________________________

Date:  __________________

Signature of Parent or Guardian of a minor subject: ______________________________

Date:  __________________

 

Sample Licensing Agreement

(Name of organization/individual) holds copyright to the (name of item) and conveys a nonexclusive, irrevocable, (worldwide) royalty-free license to the Agency for Healthcare Research and Quality (AHRQ) to use and reproduce the material (specify form and quantities—print and/or electronic, number of copies or unlimited quantities).

AHRQ agrees to include a notice of copyright on all materials that it provides and distributes. AHRQ may post (name of the item) in its entirety or a summary on its Web site. [Add this sentence if necessary: AHRQ will provide users with information regarding (name of organization/individual) for potential purchase of print copies of (name of item).] (Name of organization/individual) allows AHRQ to distribute the material and to advertise/promote its availability as described in this agreement.

The copyright holder allows AHRQ to grant permission to outside organizations to use this material without a fee, under the condition that the outside organization does not change or sell the material.

[If a third party holds the copyright, the following sentence may be included: AHRQ acknowledges that all copyright terms are in accordance with the copyright agreement signed and dated ______________ between (name of the item) and (name of the third party).]

The use of (name of item) under license by AHRQ or its agents or representatives is acceptable to AHRQ and the (name of organization/individual).

Signatures:

AHRQ Representative ____________________________ Date _______________

Copyright Holder ____________________________ Date _______________

 

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Page last reviewed February 2013
Internet Citation: Appendix 1-A. Copyright: Permission Forms and Licensing Agreement: AHRQ Publishing and Communications Guidelines. February 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/publications/pubcomguide/pcguide1apa.html