Author Anonymization Agreement

Paper Title *

Author *

Author Required to Confirm by Checking the Box

I have anonymized the patient's identity *

I verify that I have anonymized the patient's identity to be unrecognizable by others and as unrecognizable to him/her/themself as possible and to render all other individuals unrecognizable to third parties.

How Have you Protected the Patient from Identification (please confirm all that apply)?

How Have you Protected the Patient *

Thorough Disguise (of Individual Patients)

When presented, details of Anonymization patient-therapist interactions have been described so as to preclude identification of the patient.

Use of Composites

Other (please describe below)

Other protection

Anonymization Details Checklists

Category 1 - The following must be changed or omitted (Please confirm all.)

Patient name *

Patient Name

All other names *

All other names

Patient place of birth *

Patient place of birth

Patient occupation *

Patient occupation

Dates and exact length of treatment *

Dates and exact length of treatment

Organisational or other affiliations *

Organisational or other affiliations

Exact location *

Exact location

Category 2--To be disguised through change, generalization, or other methods. (Please confirm all)

Medical conditions *

Medical conditions

Age *

Age

Family and family history *

Family and family history

Details of specific traumata and other key historical events *

Details of specific traumata and other key historical events

Category 3 - To be disguised as above, unless essential to the usefulness of the case report

Race *

Race

Religion *

Religion

Historical and cultural details *

Historical and cultural details

Photographs and all other images from the treatment *

Photographs and all other images from the treatment

Other (please elaborate)

Explain why and what

Any clinical material described in this article has been properly anonymized, in accordance with the Journal’s Patient Anonymity Guidelines. By signing this agreement, I warrant that the confidentiality statements that I have provided are fully accurate and that I have read and followed the Journal’s requirements for ensuring confidentiality. To view the guidelines, visit our website: www.ncspp.org/fortda/anonymization-policy

E-signature *

Date *

Year

Month

Day

NCSPP

Northern California Society for Psychoanalytic Psychology

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