NQMC Copyright Agreement Form

____________________________________________________________________ (authorized individual name and title) on behalf of the measure author/developer/owner(s),
_____________________________________________________________________________, hereby grant to AHRQ, and its agent(s), exclusively for NQMC purposes, the following non-exclusive worldwide rights and licenses:

1.	To copy and abstract __________________________________________________'s (our organization's) quality measures ("measures"), including detailed information about the measure’s development, and to place such abstract(s) on the NQMC World Wide Web site.

Yes		No 	(circle one)

Permission* is given for (circle all that apply):
a.	Measure(s) titled _______________________________________________________ and dated ______ (attach additional sheets, as necessary, or refer to the NQMC-specific attachment)
b.	All future published revisions/updates of the measure(s) specified in (1a).
c.	All measures by our organization published to date
d.	All new measures to be published in the future (i.e., all measures from our organization that meet NQMC inclusion criteria)

2.	To place the full-text measures on the NQMC World Wide Web site.

Yes	No	(circle one)

3.	To establish links from the NQMC World Wide Web Site to your organization’s Web site: http://__________________________________________.

Yes	No	(circle one)

AHRQ and its agent(s) (ECRI) agree to provide full credit to your organization as the author/developer/owner(s) of such quality measures and to inform NQMC users about the terms governing downloading, use, and reproduction of these measures as set forth below or to refer them to your organization for such information as directed below:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________
You agree to provide to ECRI a computer-readable full-text version (if available) of your organization’s quality measure that have been accepted for inclusion in the NQMC and that will be referenced or posted at the NQMC Web Site.

You represent and warrant that you are the author of the measures and owner of your Web Site, or currently possess all rights necessary to grant the rights granted herein.  You represent and warrant that your measures do not infringe any copyright, trademark or other proprietary right of any third party.

I/we, the signators of this license represent and warrant that I am/we are the author(s) of the measures and/or possess all rights necessary to grant the license rights above to AHRQ and its agents.  I/we represent and warrant that the measures so licensed do not infringe any copyright, trademark or other proprietary right of any third party.

This agreement shall be effective as of the later date signed below and shall remain in force unless terminated by either party by giving prior written notice of not less than six months.

Name(s) of Measure Developer(s) (please print)

_______________________________________________________________________

Name(s) of individual(s) authorized to grant rights to use measure(s) referenced above:

_______________________________________________________________________

Signature(s) of authorized individual(s): _______________________________________

________________________________ (title) _____________________ Date: _______

________________________________ (title) _____________________ Date: _______

Organization:____________________________________________________________

Address:________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Telephone: ______________ Fax number: _______________ Email: _______________


ECRI will send a copy of this document to the NQMC Project Officer at AHRQ.