Authorship Disclosure Form - Authority Responsibility And Financial Disclosure/conflict Of Interest
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1Authorship Disclosure Form
Authority Responsibility and Financial Disclosure/Conflict of Interest
E
ach author is required to complete an authorship disclosure form, which must be submitted online with the
m
anuscript. If this is not possible, the submitting author should contact the Editorial office.
3.
Financial Disclosure as it relates to the subject of
Name (print)
_________
this work:
You must verify and check the box or initial
the paragraph below for submission:
E‐mail
I certify that all financial support related
Corresponding Author and Manuscript Title:
to this work is clearly identified with a
special notation in the Statement of
Interest section in the manuscript as is
which could be perceived as constituting
a financial conflict (e.g., income from a
pharmaceutical company that
m
anufactures a product used in the
1
. Autho
rship Responsibility and Contributions
s
tudy).
Please
check the appropriate boxes
Neither this manuscript nor one with
4. Financial Disclosure not directly related to
substantially similar content under my
the subject of this work.
authorship has been published or is being
You must verify and check Box 4a OR Box 4b
considered for publication elsewhere,
for submission:
except as described in an attachment; a
nd
I have participated sufficiently in the
4a. I certify that I have listed separately in
research and its writing to ke public
t
a
the Statement of Interest section of the
responsi
bility for (check 1 o
f 2 below)
manuscript all relationships, e.g.,
speaker’s fees, consultancy honoraria,
o
part of the content
equity ownership, profit‐sharing
o
the whole content
agreements, royalties, patents, research
grants from industry, from which I have
I attest that my co‐authors and I had
received compensation for professional
complete control over the preparation of
services in any of the previous three
this report and that we bear total
years, or from whom I anticipate
responsibility for its content.
receiving such compensation in the near
future.
X
Your Signature Required for Submission
Date
OR
4b. I certify that I have no financial
interests to disclose and have written a
2. NonFinancial Disclosure as it Relates to the
statement to this effect in the Statement
Subject of this Work
of Interest Section of the manuscript.
I certify that all non‐financial forms of
support for this study, e.g., gifts of drugs,
statistical support, assistance with
preparation of the manuscript is clearly
X
identified in the Statement of Interest
Your Signature Required for Submission Date
Section in the manuscript.
Each author must complete this form and send to the submitting author as a PDF. It is the responsibility of the
submitting author to upload all completed forms with the manuscript in the online submission system.
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