Authorship And Disclosure Form printable pdf download

Authorship And Disclosure Form

Longwoods Publishing 260 Adelaide Street East, No.8 Toronto, ON M5A 1N1 Canada

Tel: 416-864-9667 Fax: 416-368-4443

Authorship and Disclosure Form

______________________

Manuscript ID number

__________________________________________________________________________

Article title (ﬁrst few words)

Financial Disclosure/Conﬂict of Interest

Public trust in the peer review process and the credibility of published articles depends in

part on how well conﬂict of interest is handled during writing, peer review, and the editorial

decision-making process. Conﬂict of interest exists when an author of a manuscript or a letter

to the editor has ﬁnancial or personal relationships with other persons or organizations that

could inappropriately inﬂuence (bias) her or his actions.

This questionnaire must be completed and must be signed by every author of the above-

referenced work and returned to journal ofﬁce at the time of manuscript submission. The

above information will be used only by the Editorial Board of Healthcare Policy/Politiques de

Sante. It will not appear in print or on Longwoods website.

- - - - - Answer All Three (3) Questions - - - - -

Question 1: Have you -- or a member of your immediate family -- in the past 12 months been

engaged in any relevant ﬁnancial relationships that may present a conﬂict of interest, such as

employment, stock ownership, honoraria, royalties or paid expert testimony?

Yes (describe on a separate sheet)

Question 2: Do you discuss products or services of that commercial interest?

Yes (describe on a separate sheet)

Question 3: Did you have full access to all the data in the study (if applicable) and thereby

accept full responsibility for the integrity of the data and the accuracy of the data analysis.

Yes

Authorship And Disclosure Form