Conflict Of Interest Disclosure Page 3
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4For each question answered yes please provide full details of all such arrangements, including the entity, type
of activity and amount of compensation. If this is an industry-sponsored study you are required to disclose any
income (consulting fees, honoraria, etc.) whether greater than or less than $10,000 received from the company(s)
that sponsored the study; as well as who analyzed the data (authors versus company) and who wrote the paper
(authors versus company). Use additional sheets as necessary.
I have read the JDSM Policy on Conflicts of Interest and I certify that the information provided is true to the best of my
knowledge and that I am in compliance with the JDSM policy.
________________________________________________________________________________
Name (print)
____________________________________________________________
__________________
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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