CONTRIBUTION FORM

1. What evidence do you have that this material was effective? Please attach all formative research, pretesting results, summative evaluation, anecdotal evidence, etc.

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2. Circle Format:      Poster         Pamphlet       Video         CD         DVD         Audiotape        

                                     Novelty Item         Kit         Training Package         Other _______________

3. Original Title:____________________________________________________________________

If not English, translation into English:___________________________________________________

4. Date of Publication/Production:________________________________

5. Length (for video or audiotape): _____hr. _____ min.

6. Intended Audience: ______________________________________________________

7. Producer:______________________________________________________________

8. Author [if applicable]:________________________________

9. Artist [if applicable]:_________________________________

10. How was the material used? Please attach all relevant information about the project:

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11. Distributor [if applicable]: ______________________________________________________

12. Distributor's Contact Information: __________________________________________________

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13. PERMISSION:

We know that many of our colleagues would like to know about this material and may wish to request a copy. For this reason we ask you to sign the following:

I hereby allow the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP) Media/Materials Clearinghouse (M/MC) the non-exclusive rights to do the following with this material: :

1. Photograph and digitize the material (as an image or PDF file): ___ OK    ___ NO

2. Make a copy of the material for a qualified requester: ___ OK    ___ NO

3. Place an image/PDF of the material and information about it on the Internet: ___ OK    ___ NO

4. Provide an image/PDF file of the material and information about it on a CD-ROM: ___ OK    ___ NO

I understand that this material will only be used for non-profit educational purposes, and that the M/MC will make every effort to ensure that full and proper credit is attributed to the item. I agree that I am authorized to grant the permission herein.

Signature _________________________________________________________________

Name ______________________________________________________________________
 
Title _____________________________________________________________________

Organization ______________________________________________________________

Address ___________________________________________________________________
 
City/State/Postal Code ____________________________________________________

Country ___________________________________________________________________

Phone _____________________________________________________________________

Fax _______________________________________________________________________

E-mail ____________________________________________________________________