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Disclosure
Statement
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Manuscript Number: ____________
Each author is required to fill out this form. The
editor's interest extends to those areas relevant to the article
that broadly viewed, could be construed as constituting a conflict
of interest or the appearance thereof. This form should be submitted
upon acceptance of a manuscript. The information will be used only
in paraphrase to write disclosure statements. If there is
nothing to disclose, please indicate so.
A) Please indicate the type and extent of any:
- Consulting fees or paid advisory boards ( for the past two
years or the known future)
- Equity ownership/stock options (publicly or privately traded
firms, excluding mutual funds)
- Lecture fees when speaking at the invitation of a commercial
sponsor (for the past two years or the known future)
B) Please indicate whether you are employed by the
commercial entity that sponsored the study.
C) Please indicate whether you receive grant support from industry.
If yes, complete the next section. Yes ________ No ________
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Current grant support (include
nonprofit/government entities):
(or attach "Other Support" page)
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Total Amount
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Years Covered
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D) Do you have patents and/or royalties, serve as
an expert witness, or perform other activities for a commercial
sponsor? Please provide a brief description:
Name: _______________________________
Signature: ____________________________________
Date: ________________
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