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Copyright Clearance and Fair Use Form
Instructor Name:
*
Today's Date:
*
Course and Term(s):
*
Title of Copyrighted Work:
*
Author(s)/Editors(s):
*
Publisher
*
Portion(s) to be used (e.g., pages, timer counts):
*
URL (if applicable):
Usage (check all that apply):
*





If "other" is selected above, please explain:
Instructions:
  • Use the check boxes below to assess whether your intended use of copyrighted material is fair use or not.
  • Where the factors favoring fair use outnumber those against it, reliance on fair use is justified.  Where fewer than half the factors favor fair use, instructors should seek permission from the rights holder.
  • Not all of the facts will be present in any given situation.  Check only those facts that apply to your use.  No single item or factor is determinative of fair use.
  • Rickman Library will evaluate the information on this form and notify you of one of the two outcomes: 1) your use is fair--no other action is needed. 2) your use requires the permission of the copyright holder.
  • If permission is required, we will make the request on your behalf after verifying that this is the course of action you would like to take.
  • Rickman Library will retain a copy of this checklist for each "fair use" of a copyrighted work in order to establish a "reasonable and good faith" attempt at applying fair use should any dispute regarding such use arise.
Fair Use Checklist
Factor 1: Purpose and Character of the Use
Weighs in Favor of Fair Use:




Weighs Against Fair Use






Factor 2: Nature of Copyrighted Work
Weighs in Favor of Fair Use


Weighs Against Fair Use:


Factor 3: Amount and Substantiality of Portion Used
Weighs in Favor of Fair Use:


Weighs Against Fair Use:


Factor 4: Effect on Market for Original
Weighs in Favor of Fair Use:








Weighs Against Fair Use: