Permission Form for Use of Master’s Thesis
To: Dean of the Keio University Graduate School of Science and Technology
Director of the Keio University Media Center for Science and Technology
I grant the following permission of use for the thesis I wrote:
Date (mm/dd/yyyy):
Affiliation□ Fundamental Science and Technology//Laboratory:□ Integrated Design Engineering□ Open and Environmental Systems
Student ID number
Full Name
Contact Details

Tel:*ones valid even after graduation

E-mail:Title of Thesis
Japanese

Keywords for search index(3 to 5 words each in Japaneseand English)
EnglishOption for releasing abstract and main text of thesis in electronic formats:Prior to permitting to release your thesis (accessible only on Yagami Campus), confirm that the thesis complies withthe terms 1 to 10 (on the reverse side) for the protection of intellectual property and research ethics, and select oneof the following:□Entire work ; To be accessed immediately.
□Entire work ; Access to the thesis may be delayed until April 1, (yy)□Abstract only ; To be accessed immediately.
□Abstract only ; Access to the abstract may be delayed until April 1, (yy)□Embargo (withhold) from ΣStarReason for embargo: □To protect information such as intellectual property.
□Other (Specify if possible):※The author name and title will be released on ΣStar regardless of the scope of disclosure for the abstract andmain text of the thesis.

rev.2022-10-31

Reverse of Permission Form for Use of Master's Thesis

Terms to confirm for the protection of intellectual property and research ethics.
1・ Your research is neither a joint nor a commissioned research.
・ Though your research is joint or commissioned research, you have received permission from theother researchers/client or you do not need to get permission.

2・ Your thesis does not contain information related to patent matters.
・ A patent application has been filed or is scheduled to be filed.
(If you do not want the content of your patent application to be known even after it has been filed,
set the release date for your thesis about one-and-a-half years after the patent application.)

3・ Your thesis does not include content that you do not want to disclose, such as software sourcecode.
・ Though your thesis includes content that you do not want to disclose, the sections in question arepart of the appendix and have been removed from the submitted file.

4・ Your thesis properly references the sources of cited figures and tables.

5・ Your thesis properly references previous research.

6・ Your thesis does not contain content that could be suspected of having been written by others.
・ Your opinions and those of others are distinct and have been referenced appropriately.

7・ Your research did not use human subjects or human specimens, cells, or organs.
・ Though your research made use of one or more of the above, there are no problems as this wasapproved by the Bioethics Committee of the Faculty of Science and Technology.

8・ Your research did not involve animal experiments.
・ Though your research involved experimenting on animals, there are no problems as theseexperiments were approved by the Keio University Institutional Animal Care and Use Committee.

9・ Your thesis does not include photographs of others.
・ Though your thesis includes photographs of others, you have received permission for use fromthose in question or the photographs have been edited to maintain privacy.

10・ Your research does not contain any personal information.