Authors Conflict of Interest Disclosure Questionnaire.

(Download. Click Here PDF.)



Manuscript number____________________

Author’s name________________________


Each author shall sign and complete this form.

A. Author Conflict of Interest

Each author most disclose any financial, personal or professional relationships with other people or organizations that could reasonably be perceived as conflicts of interest or as potentially influencing or biasing their work.

Author’s disclosure will appear after “Acknowledgements” section in the accepted article.

First, each author is required to identify all relationships within the last 2 years that are relevant to the topic of the manuscript and might be perceived as a real or potential conflict of interest. A relationship is relevant if the relationship or interest relates to the topic in terms of any of the following: the same or similar subject matter or topic; the same, similar or competing drug or device, product or service, intellectual property or asset; a drug or device company or its competitor; or has the reasonable potential to result in financial, professional or other personal gain or loss for you, members of your household or employer.

Please insert explanatory information describing each relationship in each category in the chart below. Note these definitions of the categories: “Research Grant” includes principal investigator, collaborator or consultant and pending grants as well as grants already received. “Other Research Support” includes receipt of drugs, supplies, equipment or other in-kind support. “Speaker/Honoraria” includes speakers bureau, symposia, and expert witness. “Ownership Interest” includes stock, stock options, patent or other intellectual property.

If any author has no relationships or conflict to disclose, the author must indicate “None” in the appropriate categories in the chart.

Second, each author is required to classify each disclosed relationship as either “Significant” or “Modest”. A relationship is considered to be “Significant” if (a) the person receives US$ 10,000 or more during any 12 month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock of share of the entity, or owns US$ 10,000 or more of the fair market value of the entity. A relationship is considered to be “Modest” if it is less than “Significant” under the preceding definitions.

 

If additional space is necessary, please provide additional detail in the space below or on an attached sheet:


B. Institutional Conflict of Interest
Are you aware that your academic institution or employer has any financial or ownership interest directly relation to the topic or subject matter discussed in this manuscript?

____No

____Yes. Please describe in the space below or on an attached sheet:


Author’s name_________________________

Author’s signature_______________________

Date__________________________________
 

back