USU Manuscript Approval/Clearance Form

Uniformed Services University
of the Health Sciences

Manuscript Approval or Clearance

INITIATOR

1. USU Principal Author:

2. Academic Title:

3. School/Department:

4. Phone:

5. Type of publication (submitted to): ____Paper __Article __ Book

USU WWW Home Page at (URL):

Other:

6. Manuscript Title:
7. Intended publication ((include organization if appropriate):

8. Required by (publication receipt) date:

9. Date of submission for USU approval:

CHAIR OR DEPARTMENT HEAD APPROVAL

1. Name: Robert E. Goldstein, MD, Chair

2. School/Dept.: Medicine

3. Date:

4. __Higher approval clearance required (for University-, DoD or US Gov’t-level policy, communications systems or weapons issues review*)

*Note: It is DoD policy that clearance of information or material shall be granted if classified areas are not jeopardized, and the author accurately portrays official policy, even if the author takes issue with that policy. Material officially representing the view or position of the University, DoD , or the Government is subject to editing or modification by the appropriate approving authority.

__Chair or Department Head Approval:___________________________

Signature, Date

(If additional approval or clearance is required, see other side of form)

USUHS Form 5230 (VAM) (10/99)

P. 2

DEAN APPROVAL

1. Name:

2. School/Department:

3. Date:

4. __Higher approval clearance required (for University-, DoD or US Gov’t-level policy, communications systems or weapons issues review").

*Note: It is DoD policy that clearance of information or material shall be granted if classified areas are not jeopardized, and the author accurately portrays official policy, even if the author takes issue with that policy. Material officially representing the view or position of the University, DoD, or the Government is subject to editing or modification by the appropriate approving authority.

__Dean Approval

______________________

Dean Signature/Date

DIRECTOR, UNIVERSITY AFFAIRS (OUA) ACTION

1. Name:

2. Date:

3. __USU Approved or

__DoD Approval/clearance required

4. __Submitted to DoD (Health Affairs) on (date):

or

               __Submitted to DoD (Public Affairs) on (date):

5. __DoD approved/cleared (as written) or __DoD approved/cleared (with changes)

6. DoD clearance/date:

7. DoD Disapproval/date:

                          _________________________________
                          Director, OUA Signature                 Date

SLevy 3/03