Other Requests - Publication, Reproduction, Research

Other Requests - Publication, Reproduction, Research

All fields with an asterisk (*) are mandatory
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is your role in palliative care?*
Which tool(s) are you requesting permission to use?*

Palliative Performance Scale Version 2 (PPSv2)Bereavement Risk Assessment Tool (BRAT)Bowel Performance ScaleRespiratory Congestion ScalePsychosocial Assessment Tool10 Steps for Better Prognostication
Please specify what language(s) you would like for the PPSv2:*
Would you be using the tool(s) for profit?*

YesNo
How would you be using the tool(s)?*

Book (Printed or electronic)Website displayBrochures/PostersConference/PresentationEducation materialCourse contentElectronic Medical Record (EMR)Printed clinical formJournal articleTranslationClinical trialOther
If you selected "Other" please specify how you would like to use the tool*
Should the results of your study be published, we require that only the sample version of the tool be sent to publication (included in the release after consent)*

I agree to this condition
If you are requesting to display the tool on an open-access website, we require that you only use the sample version of the tool(s)*

I agree to this condition
If you are requesting to use the PPSv2 in an Electronic Medical Record (EMR), we require that you submit a screenshot of the tool on your system before you receive the copyright*

I agree to this conditionN/A
Please provide us more information about the book
Tentative title of the book*
What edition is this?*
Expected Year of Publication *
Publisher*
Please provide more information about how you will use the tool(s)*
Please review and check each clause to confirm your agreement with the copyright permission terms:*

Permission is granted for non-exclusive rights to publish the tool(s) in the requested language only.A credit line will appear at the bottom of the tool(s) and will include Copyright Victoria Hospice Society, BC, Canada www.victoriahospice.org.No modifications to the content, structure and meaning of the tool(s) is allowed.The tool(s) must be published with complete usage instructions, including the chart, instructions for use and definition of terms.The tool(s) must not be used in any way that generates profit from the tool(s) itself, including resale, licensing, or commercial distribution.
Should be Empty: