CUHAS|Permission to Publish Application Form

CATHOLIC UNIVERSITY OF HEALTH AND ALLIED SCIENCES (CUHAS)

P.O. Box 1464, Mwanza, Tanzania

Phone: (255) 28-250-0881 | Fax: (255) 28-250-2678

Date:

Paper Information

Title of the Paper

Author and Institutional Details

Name of the Corresponding Author

Name of the Institution

School/Faculty

Department

Academic Rank of Applicant

Research and Journal Information

Ethical Clearance Number

Name of the Journal (if identified)

Is the journal indexed in PubMed/SCI?

Source of Research Fund

Collaboration and Supervision

Was the research inter-departmental?

Was the research multi-institutional?

Junior Staff and Student Involvement

If the author is a senior staff, does the research involve a junior staff?
Yes No

If yes, has the clearance been obtained for the student(s)/junior staff?
Yes No

Does the article stem from student elective research reports?
Yes No

If yes to any of the above, mention all individual clearance numbers (see slot 4):

Final Declaration

Signature of the Applicant

Date

Forward the completed form and e-copy of the manuscript to permissiontopublish@cuhas.ac.tz