public affairs office non protocol publication learance

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WRNMMC Public Affairs Office, Building 1—Tower, Floor 11

Public Affairs Office

Non-Protocol Publication Clearance

WRNMMC Author(s)/Presenter(s):

Phone Number/Office Location:

Email:

Title/Rank/Affiliation:

Department Chief/Commanding Officer:

Who is the Audience:

Date to be Presented:

Do you have approval from your department head?

MANDATORY

General Disclaimer

The views expressed in this [article, speech, presentation, etc.] are those of the author and do not reflect the official policy of the

Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. Page#: ________

MANDATORY ABSTRACTS

General Disclaimer

Please note, abstracts are not cleared in lieu of final text/presentation. Final text/presentation must still be submitted for clear-

ance. The views expressed in this [article, speech, presentation, etc.] are those of the author and do not reflect the official policy of

the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. Page#: ________

Image(s) Permission Do you have expressed permission from the owner to use any and all images? Included but not limited to: photo(s), clip-art, logos*,

tables, graphs, medical documents such as scans or charts, and products, etc. copied from the internet or elsewhere.

Authorization for Disclosure of

Medical or Dental Information

DD Form 2870

If you have included a patient(s) in your presentation, do you have an appropriate DD2870** form signed and dated citing the

specific use of their information? Please provide with your submission.

Personal Information Do you have any personal information such as phone number, photos, or anecdotal references that are NOT relevant to your

presentation? If so, please remove per the privacy act.

Medical Disclaimer The identification of specific products or scientific instrumentation does not constitute endorsement or implied endorsement on

the part of the author, DoD, or any component agency.

Endorsement

Guidelines:

Included but not limited to: use of specific brand names, use of URLs that is anything other than .gov or .mil, products, publica-

tions, scientific instrumentation, and software is strictly prohibited as per DOD Joint Ethics Regulations 5500.7-R.

Before submitting please be sure your submission adheres to the following:

Manuscript Book Poster Workshop

Abstract Presentation Article Other Type of publication to be cleared:

Signature ________________________________________ Date ___________________

*Please see the attached Basic Guidelines for the use of the Command Logo ** DD2870 form attached

Once this form is completed, scan along with any necessary permission(s) or attachments.

Subject line of the email should read as follows:

PAOPubReq– LASTNAME-TYPEOFPUB-DATENEEDED (example: PAOPubReq-Reed-Manuscript-12Dec2016)

EMAIL TO: dha.bethesda.ncr-med.mbx.wrnm-irbnet-pao-review@mail.mil

(Not adhering to the requested format will result in delays.)

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WRNMMC Public Affairs Office, Building 1—Tower, Floor 11

Public Affairs Office

Non-Protocol Publication Clearance