Photocopy / Interlibrary Loan Form / Please write clearly using one form per request
Library Card No:
Full Name:
Job Title:
Dept/Address:
Work Base:
Phone/Bleep:
Email:
Date: / / / /
This request is for:
Education
Patient Care
Research
/ Preferred method for receipt:
Send to my department
Email me the article
Collect from Library
Please contact me on:
Other (please state):
Publication title:
Author(s):
Article title:
Publisher: / ISBN/ISSN:
/ Year:
Volume:
Issue:
Pages:
Edition:
Copyright Declaration
Please supply me with a single copy of the journal article referred to above, which I require for the purposes of research for a non-commercial purpose or private study. I declare that:
- I have not previously been supplied with a copy of the same material by you or any other librarian
- I will not use the copy except for research for a non-commercial purpose or private study, and will not supply a copy of it to any other person
- To the best of my knowledge, no person with whom I work or study has made or intends to make, at or about the same time as this request, a request for substantially the same material for substantially the same purpose
- I understand that if the declaration is false in a material particular the copy supplied to me by you will be an infringing copy and that I shall be liable for infringement of copyright as if I had made the copy myself.
FOR LIBRARY USE ONLY
Library staff initials: / Date request received: / / / /
Reader category: / Date request processed: / / / /
NHS Staff/Student on Placement = Authorised User? / Processing time: / Within 24hrs / Within 48hrs
Yes / No:
Email / Telephone / In Person / Post / Inter/Intranet
Received by:
Delivered by:
Request type: / Loan / Photocopy / Notes:
Download
Scheme:
Library:
Class mark:
Date item requested: / / / /
Date item received: / / / /
Time taken: (Days)
Item barcode:
Due date: / / / /
2nd / / / /
3rd / / / /
4th / / / /
Date item returned: / / / /
NHS Wales (NHS Wales CLA Licence only applies to authorised users, all other requests supplied under Copyright Act)
Own Print Stock / Health Board Print Stock / Health Board
E Journals / AWHILES / NHS – E-Library / Cardiff
E – Jnls / Cardiff Health Library
Outside NHS Wales Licence(Copyright Act – library privilege applies)
Cardiff: Other Libraries / Free on Internet / NULJ / Psychiatric Libraries / British Library / Other:
Signature of requestor on collection of item:
Signature: / Date: / / / /
Please return this form to the above Library where it will be dealt with as soon as possible[NTO 17-10-2017]