Conflict Of Interest Disclosure Page 2
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4CONFLICT OF INTEREST DISCLOSURE
Name (print) ______________________________________________________________________________
Rapid Review Manuscript # (complete if known) MS # ___________ - ___
Title of manuscript:
This declaration reflects all current potential conflicts of interest. Any significant changes in this
YES
NO
declaration should be reported to the Editor-in-Chief of JDSM.
1. Do you currently participate or have you participated in the last 24 months in research
activities supported by a for-profit business or granting agency whether or not the
individual or family member has a financial interest? This support may be in the form of
grants, gifts or awards, financial or otherwise.
2. Do you currently or have you within the last 24 months had any relationships with a
business including directorships, trusteeships, management relationships or paid speaking
engagements?
3. Do you currently or have you within the last 24 months had personal financial interest in a
business exceeding $10,000 per year; including honoraria, consulting fees or any form of
compensation?
4. Within the past 24 months have you received substantial gifts, discounted or free use of
material or equipment provided by a business?
5. Is this an industry-sponsored study?
6. Does your paper report on a product or service (either in development or currently
marketed) for which you serve as an advisor or consultant?
7. Do you have any other potential conflicts of interest that should be disclosed?
If you answered
YES
to
any of the questions
above, please provide details as
¨
instructed and sign on the following page.
If you answered
NO
to
all of the questions
above, sign below.
¨
I have read the JDSM Policy on Conflicts of Interest and certify that I have no potential conflicts in any of the above
categories and that I am in compliance with the JDSM policy.
____________________________________________________________
__________________
Signature*
Date
* Note oN electroNic sigNatures: Signature fields can be left blank if you do not have an electronic signature. However, you will need to print
out the form, sign it, fax a copy to Rosanne Money at (630) 737-9790, or scan and email to .
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