SAMPLE
Consent Agreement for Depositing Doctoral Dissertation
Date：YYYY / MM / DD
To the Director of the University Library,
To the Dean of the Graduate School of Natural Science and Technology, Shimane University,
Course○○○○○○○○○○○○

Student ID○○○○○○Name (self-written)○○○○○○○○○

seal印㊞

I hereby give my consent to deposit my doctoral dissertation on the Shimane University Institutional
Repository. I also agree to share the dissertation, when the unavoidable circumstances which have disabled meto do so are resolved.
Title ofDissertation in○○○○○○○○○○○○○○JapaneseTitle ofDissertation in○○○○○○○○○○○○○○English☐ I agree to deposit my dissertation within one year after the conferral of the degree.
 Due to the following reasons, I request to deposit my dissertation on the designatedConditions for
Depositiondate.
※ Note that a reason must be recognized “unavoidable” if delaying the deposition for
more than one year after the conferral of the degree.
【Requested Date of Deposition】YYYY / MM / DD
【Reason】☐ My dissertation includes content that is currently being submitted or will besubmitted to academic journals in the future.
 The regulations of the journal in which part of my dissertation was published preventme from depositing for a certain period of time.
☐ Other (Please specify

If your dissertation contains citations
Handling ofCopyright
Check thecheckboxes in theright column.

from other works

If you have co-authors for thedissertation and related papers) The sources have been clearly cited.

 All co-authors have agreed with thisdeposition. (Verbal consent is acceptable)Publication Progress

Copyright Policy
 The dissertation can be shared within one year.

Journal Title：○○○○○○○☐ The dissertation cannot be shared within one year.

ISSN：○○○○－○○○○

Specify how many months the deposition on the institutional repository isVol. No.：Vol.○○ No.○○

restricted for, after the publication in the journal

Page No.：P○○～P○○
Date of issue： YYYY / MM / DD
DOI：○○○○○○○○○

Embargo period:months☐ Sharing the dissertation is prohibited.
For the relevant peer-reviewed papers, please check the copyright policy of theaccepted manuscript.
☐ The dissertation can be shared within one year.

Journal Title：○○○○○○○

Publication

Specify how many months the deposition on the institutional repository isVol. No.：Vol.○○ No.○○

restricted for, after the publication in the journal

Page No.：P○○～P○○

Embargo period: ○○Date of issue： YYYY / MM / DD
DOI：○○○○○○○○○

Check if the publisher’s
regulations on the use of
copyrighted works permits
the deposition of full-text orpart of your dissertation onthe institutional repository.
● This section needs to be
filled if all or part of thedissertation has been
published or accepted inan academic journal.

 The dissertation cannot be shared within one year.

ISSN：○○○○－○○○○months☐ Sharing the dissertation is prohibited.
For the relevant peer-reviewed papers, please check the copyright policy of theaccepted manuscript.
☐ The dissertation can be shared within one year.

Journal Title:☐ The dissertation cannot be shared within one year.

ISSN:

Specify how many months the deposition on the institutional repository isVol. No.:

restricted for, after the publication in the journal

Page No.:

Embargo period:

Check the copyright policy of the journal in which the related papers was published.
Date of issue:

months☐ Sharing the dissertation is prohibited.

If the copyright remains with the author, mark “The dissertation can be shared within
DOI:

For the relevant peer-reviewed papers, please check the copyright policy of theone year”.
● Contact the University
accepted manuscript.
Library if you are unable
to confirm the publisher’s☐ The dissertation can be society,shared within
one theiryear. websites or
If the copyright is held by the publisher/academic
check
copyright policy.
Journal Title:☐ The dissertation cannot be shared within one year.

contact them for their copyright policy and mark the item that applies.
ISSN:

Specify how many months the deposition on the institutional repository isVol. No.:
restricted for, after the publication in the journal○Howto Check Copyright Policy onEmbargo
the Internet○
Page No.:
period:monthsDate of issue:
InternationalJournals☐ Sharing the dissertation is prohibited.

DOI:
the relevantpleasepeer-reviewed
papers,please check the copyright policy of theYou
can use the Sherpa Romeo. For moreFor
information,
check theiruser guide.
accepted manuscript.
[https://v2.sherpa.ac.uk/romeo/resources/user-guide.pdf]
Japanese Journals

Journal Title:☐ The dissertation can be shared within one year.
☐ The dissertation cannot be shared within one year.

You can use the "Society Copyright Policies in Japan" database.

ISSN:

Specify how many months the deposition on the institutional repository isVol. No.:

restricted for, after the publication in the journal

Page No.:

Embargo period:[https://jpcoar.repo.nii.ac.jp/records/216]

Date of issue:

months☐ Sharing the dissertation is prohibited.

For the relevant
peer-reviewed papers, please check the copyright policy of theThe following fields will beDOI:
filled out and stamped by your academicadvisor.
accepted manuscript.

Academic Advisor’s
Confirmation

This dissertation was checked using the plagiarism detection tool “iThenticate”, and it was confirmedthat there was no plagiarism.
Name○○○○○○○○○

seal印㊞※This agreement is necessary to grant the university the right of reproduction and the right to transmit to public of yourdoctoral dissertation for the purpose of deposition on the Internet. It does not mean to transfer the copyright to theuniversity.
※If your doctoral dissertation includes content that is currently being submitted or will be submitted in the future, you will
be asked to submit this agreement again when your dissertation is accepted.