（別記様式－後１）

ExampleAcademic Advisor’s
Seal

Receive the seal from your academic advisor.

春日SealDissertation Review Application
MM DD, 20XX
To Dean of Graduate School of Library, Information and Media Studies,
Doctoral Program in Library, Information and Media Studies,
Graduate School of Library, Information and Media Studies
Doctoral Program

A Shachihata seal is not acceptable.
The signature can be substituted for theAcademic Year of Enrollment 20XXName

TSUKUBA Taro

Student ID Number 20XXXXXXX

筑波Seal/Signature

Pursuant to the provisions of Article 5 of the Degree Regulations of the University of Tsukuba, I hereby apply forreview of my doctoral degree (○○○○○○) with five copies as attached.

Fill in the name of the degree you wish.

Notes

1. Abstract of doctoral dissertation (in Japanese):

1 copy2. Abstract of doctoral dissertation (in English):

1 copy3. Author bibliography for dissertation:

1 copy4. Offprints or copies of papers that forms a core of the dissertation:

2 copies

5. Petition on internet publication:
6. Non-plagiarized dissertation report:
7. Ethical review report: 1 copy
Note: 1. The applicant shall put his/her name and seal or signature.
2. For the name of the degree, enter one from “Library and Information Studies”, “Informatics”, or “Philosophy.”
3. For writing the dissertation, be sure to refer the "Degree Application Guide (Doctoral Program)."
4. If there is another reference material for degree review, submit one copy.

Example

A Shachihata seal is not acceptable.

（別記様式－後２）

Submitted on MM DD, 20XX

Abstract of Dissertation (in Japanese)
Graduate School, University

Fill in the name of the degree you wish.
Graduate School of Library,of Tsukuba

DegreeInformation and Media Studies
Doctoral Program

Doctoral Degree (〇〇〇)

Student IDName inNumber

Katakana

20XXXXXXX

ツクバタロウTSUKUBA Taro

Name

筑波

Seal/Signature

Title
Research on ○ ○ ○OutlineThe outline of the dissertation to be applied, approx.
4,000 characters in Japanese.

〇〇・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・

If there are more than two pages, include“the degree name, student ID number, name,seal/signature, and the title” shall be described, andalso "1/2, 2/2..." shall be printed at the bottom.
Remarks: When writing, be sure to refer the "Degree Application Guide (Doctoral Program)."

１／２

ExampleA Shachihata seal is not acceptable.

（別記様式－後３）

Submitted on MM DD, 20XX

Fill in the name of the degree you

Abstract of Dissertation (in English)
Graduate School, University of Tsukuba

Graduate School of Library,Degree

Information and Media Studies
Doctoral Program

Doctoral Degree (〇〇〇)

Student ID

Name inNumber

Katakana

20XXXXXXX

ツクバタロウTSUKUBA Taro

Name

筑波

Seal/Signature

Title
Title (English)

Research of ・・・・・・・・・
The outline of the dissertation to be applied, approx. 1,200 words inAbstractEnglish.

Ａ・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・If there are more than two pages, include“the degree name, name, seal/signature, and the title”
shall be described, and also"1/2, 2/2..." shall beprinted at the bottom.
Remarks: When writing, be sure to refer the "Degree Application Guide (Doctoral Program)."

１／２

（別記様式－後４）

ExampleA Shachihata seal is not acceptable.
Submitted on MM DD, 20XX

Author Bibliography for Dissertation
Graduate School, University ofFill in the name of the degree you wish.

Tsukuba
DegreeGraduate School of Library,Student ID
NumberInformation and Media Studies
Doctoral Program

Doctoral Degree (〇〇〇)Title
Research on ○ ○ ○（Research on …）

Katakana

ツクバタロウTSUKUBA TaroName筑波Seal/Signature

Write the title of the dissertation. If the title is in Japanese, the title in
English shall be written in (). If the title is in English, the title inJapanese shall be written in ().
* The title in Japanese is not required for English Program students.

Methods and timing of printing and publication
・・・・・・・・・・・

20XXXXXXX

Name in

When writing, refer to the example described in "3. Author
Bibliography for Dissertation” of “II. For Doctoral Dissertation
Review” in “Degree Application Guide" (from p20) and fill in.

Core papers of the dissertation

1) Peer-reviewed academic journals[Example_1] Taro Tsukuba, Hanako Tsuchiura, “Research on ○○○○,” Journal of the Japan Society of ○○○○, Vol.2, No.3, 2016, pp.234-240.
[Example_2] Taro Tsukuba, “Research on ○○○○,” Journal of the Japan Society of ○○○○, Vol.4, No.5, 2017 (accepted).
* Be sure to attach a letter that provides evidence of acceptance and publication of the paper.

2) Peer-reviewed proceedings paper at international
conferences or Peer-reviewed bulletin paper

List two or more core papers in the following categories 1)to 2).
Write the name of the categories from 1) to 2). Write"None" on the blank category.

The core
papersRepetitive
should beControl
written Algorithm
following for
the Robotmethod[Example_3] Taro Tsukuba and Hanako Tsuchiura,“A Frequency
Domaindescribed in the "Degree Application Guide" in principle.
Manipulators”, Proc. of the 2nd Motion and Vibration Control Conf., Yokohama, Aug 2016, pp.12-20.
(However, if it is difficult to follow the described method,[Example_4] Taro Tsukuba and Hanako Tsuchiura,“An Algorithm for Robot Manipulators”, Proc. of the 3rd Motion andthe volume or issue numbers, etc. should be subject to theVibration Control Conf., New York, Jul 2017 (in press).
notation of the offprints or its copies.)
List all authors, and underline the names of the degreeapplicant.
(In the case of the sole author, underline is not required forthe name of the degree applicant.)
Attachdocuments
thatcan be judged by the mechanism ofRemarks: When writing, be sure to refer the "Degree Application
Guide(DoctoralProgram)."the peer review system of the core papers.

Example（別紙様式－後１０）
Appended Form 10
インターネット公表に関する申出書
Request for Non-disclosure / Disclosure on the Internet of My Dissertation

Date:○○年 ○月○○日
MM DD, YYYY

筑波大学長 殿
To: President of the University of Tsukuba

筑波大学大学院
University of Tsukuba Graduate School and Programs:
博士後期課程 図書館情報メディア研究科 図書館情報メディア専攻
Doctoral Program in Library, Information and Media Studies
Graduate School of Library, Information and Media Studies（*博士後期課程学位プログラム）(*Doctoral Program in)
Enrollment Year: 20XX
Student ID Number: 20XXXXXXX（住所 （論文博士のみ記載）
Address (*For the candidate of the doctoral degree by way of dissertation only):
Name
Signature:[Full Name (Type):

TSUKUBA Taro 印
筑波

A Shachihata seal is not acceptable.
The signature
Seal can be substituted for the seal.

]

博士学位論文のインターネット公表に関して、下記のとおり申し出ます。
I hereby request that my doctoral dissertation to be disclosed or not be disclosed on the internet as is stated below.

Check one of the boxes.

記Details

1. 論文の全文をインターネット公表することについて
Regarding disclosure on the internet of the full text of the dissertation,■
特に問題はない
There is no problem at all.
□
公表に支障がある（チェックした者は以下の事項にも回答すること）
To release my dissertation would be difficult for me.
(Please answer the following, if you have any problem.)2. 論文の全文をインターネット公表できないやむを得ない事由
The full text of my dissertation cannot be disclosed on the internet due to the following unavoidable reasons.
*Please tick the boxes below where appropriate.
It contains:□ 立体形状による表現を含むためThree-dimensional materials□ 著作権保護、個人情報保護等の理由による
Copyrighted materials belonging to others and / or personal information□ 書籍などの出版刊行予定のためMaterials to be scheduled for publication in specialized books, etc.
□ 学術ジャーナルへの投稿を予定しているためMaterials to be scheduled for submission to academic journals□ 特許等の申請によるPatent-pending materials□ その他（）OthersIf selected "To release my dissertation would be
difficult for me." in 1, check one of the boxes.

3. 上記事由の詳細
Give detailed explanations; include the corresponding pages, name of the publishers/ magazines/journals, and dateof issues/publications.
（該当するページや出版社、雑誌、ジャーナル等の名称とその発行または掲載時期などを含めて、詳細な理由を記載すること）○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○If selected "To release my dissertation would
be difficult for me." in 1, be sure to fill in.

4. やむを得ない事由の解消（予定）時期□ 解消しない□ 〇〇年 〇月頃
(Estimated) Date of resolution of the unavoidable reason□ It would not be resolved.
□ It would be resolved by about

MM DD, YYYY.

Example（別記様式－後１３）(For Doctoral Degree by Course Work)MM DD, YYYYTo Dean of Graduate School of Library, Information and Media Studies,

Non-plagiarized dissertation report

We checked the final version of the thesis using the plagiarism checking tool “iThenticate”.

ApplicantDoctoral Program in Library, Information and Media Studies
Student ID Number: 20XXXXXXX
N a m e: TSUKUBA Taro

筑波

(Signature or, Name and Seal)

Academic Advisor

A Shachihata seal is not acceptable.

Af f i l i a t i o n: Faculty of Library, Information and Media ScienceN a m e: KASUGA Hanako

春日(Signature or, Name and Seal)Exampleyyyy mm dd

To: Dean of the Graduate School of Library, Information and Media Studies
Ethics review report
The submitted doctoral dissertation underwent the necessary ethics review of its entries and wasconfirmed to have approval as stated below.
1. Is something that is required by the ethics review found in the entries of the dissertation?
□ Yes□ No (For 2 and 3, no response needed.)

Place a check mark ✔ for appropriate
persons.

2. Write down the approval number, etc. with the implementing organization of the ethics review
where the approval was received.

Answer only if a check mark ✔was placed in “Yes” in 1.

Name of the Implementing Organization:
Approved number, etc.: Write “Approved number” and “Approved date”
3. Confirm the following matters and place a check mark ✔.

Answer only if a check mark ✔ wasplaced in “Yes” in 1.
□ The registration of all names as implementers, etc. in the ethics review related to thesubmitted dissertation by the person submitting the dissertation.

□ The date of approval of the ethics review is before the date of implementation ofinvestigations or experiments found in the entries of the dissertation.

□ There is no discrepancy between the entries of the dissertation and entries approved in theethics review. (It is unnecessary for all approved entries to be in the dissertation, however,investigations or experiments that should undergo ethics review other than the entries
approved must not be in the dissertation.)

Person submitting the doctoral dissertation
Doctoral Program in Library, Information and Media Studies, Graduate School of Library,
Information and Media Studies
Student Number: 20XXXXXXX
Name:Taro Tsukuba

Tsukuba(Signature or Name and Seal)

Faculty member in charge of research guidanceAffixing a self-inking stamp is not allowed.

Affiliation: Faculty of Library, Information and Media Science
Name: Hanako Kasuga

Kasuga(Signature or Name and Seal)