University of Technology, Sydney

BACHELOR (HONOURS)

SUBMISSION OF DISSERTATION FORM

UTS: HEALTH

The following statement is to be signed by the student and their supervisor(s) and forwarded to the Responsible Academic Officer (RAO), before the despatch of the dissertation to the approved examiners.

Student’s Family Name______

Student’s First Name______Student No.______

Course ______

Dissertation Title______

______

______

SUPERVISOR/S TO COMPLETE

The undersigned do hereby state that:

1. the above student’s work, including the dissertation, has been completed to my/our satisfactionand the dissertation is ready for examination

1. ethics clearance was obtained in accordance with UTS policies on human and animal research
2. an oral presentation of the dissertation has been made

______

Principal Supervisor Alternate/Co-Supervisor

______

DateDate

Supervisor’s/Co-Supervisor’s/Alternate Principal’s Comments:

______

______

______

STUDENT TO COMPLETE

Please circle as appropriate and sign where necessary, to complete the form:

I certify that this dissertation meets the requirements for dissertations as set out in the Faculty of Health Bachelor of Nursing (Honours) and Bachelor of Midwifery (Honours) Handbook as appropriate, and the presentation requirements therein Yes / No

I certify that the work in this dissertation has not previously been submitted for a degree nor has it been submitted as part of requirements for a degree except as fully acknowledged within the text. Yes / No

I certify that the dissertation has been written by me. Any help that I have received in my research work and the preparation of the dissertation itself has been acknowledged. In addition, I certify that all information sources and literature used are indicated in the dissertation. Yes / No

I certify that I have received ethics clearance from the appropriate authorities in accordance with UTS policies on human and animal research. Yes / No/NA

I understand that if I am awarded the degree, I will submit two bound copies to the Faculty; the Faculty shall retain one copy of the Faculty and other copy for the Principal Supervisor. Yes / No

This dissertation contains confidential material, that, under UTS Rule 11.17.4. should have restricted distribution and disclosure, until (date to not normally exceed two years) Yes / No

If Yes,please attach a copy of the approved non-disclosure agreement (typically, a signed agreement with an industry partner negotiated through the Research and Innovation Office).

I understand that the dissertation will be released on this date, unless an extension is granted upon my, or RIO’s request.

Only if restricted distribution and disclosure is requested, the Supervisor and RAO are to sign agreement here:

Supervisor to sign:RAO to sign:

Student’s Signature: Date:

I, as the Responsible Academic Officer, endorse the above statements and approve the submitted dissertation for examination by the approved examiners.

Name

SignatureDate

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