Conflicts of Interest

Date: …………………………………………………………………………………………….

Your name: ……………………………………………………………………………………………

Manuscript Title: …………………………………………………………………………………………….

Manuscript Number (if known); …………………………………………………………………………………………….

In the interest of transparency, we ask you to disclose all relationships/activities/interests listed below that are related to the content of your manuscripts. “Related” means any relation with for-profit or not-for-profit third parties whose interests may be affected by the content of the manuscript. Disclosure represents a commitment to transparency and does not necessarily indicate a bias. If you are in doubt about whether to list a relationship/activities/interest, it is preferable that you do so.

The author’s relationships/activities/interests should be defined broadly. For example, if your manuscript pertains to the epidemiology of hypertension, you should declare all relationships with manufacturers of antihypertensive medication, even if that medication is not mentioned in the manuscript.

In item #1 below, report all support for the work reported in this manuscript in this manuscript without a time limit. For all other items, the time frame for disclosure is past 36 months.

Please fill the attached pdf and submit it with the manuscript. 

  Name all entities with whom you have this relationship or indicate none (add rows as needed) Specifications/Comments (e.g., if payments were made to you or to your institution)
1 All support for the present manuscript (e.g., funding, provision of study materials, medical writing, article processing charges, etc.) No time limit for this item.
 
2 Grants or contracts from any entity (if not indicated in item #1 above).
 
3 Royalties or licenses
 
4 Consulting fees
 
5 Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events
 
6 Payment for expert testimony
 
7 Support for attending meetings and/or travel
 
8 Patents planned, issued or pending
 
9 Participation on a Data Safety Monitoring Board or Advisory Board
 
10 Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid
 
11 Stock or stock options
 
12 Receipt of equipment, materials, drugs, medical writing, gifts or other services
 
13 Other financial or non-financial interests