Conflict of Interest Statement

The following form must be completed and submitted separately by each author. For example, if there are three authors, three individual forms must be submitted. Each author must sign, print or type their name, and date the form.

In addition, one BLINDED Conflict of Interest Statement (without author names) must be submitted for each manuscript containing all author disclosures.

If no disclosure is required for any item below, please write or type "None" at the end of each statement.

Individual Author Disclosure Form

Manuscript Title:
_______________________________________________________________

Manuscript Number (if available): ______________________

1. Royalties from a company or supplier
(The following conflicts were disclosed):

_________________________________________________

_________________________________________________
2. Speakers' paid presentations for a company or supplier
(The following conflicts were disclosed):

_________________________________________________

_________________________________________________
3. Paid employee for a company or supplier
(The following conflicts were disclosed):

_________________________________________________

_________________________________________________
4. Paid consultant for a company or supplier
(The following conflicts were disclosed):

_________________________________________________

_________________________________________________
5. Unpaid consultant for a company or supplier
(The following conflicts were disclosed):

_________________________________________________

_________________________________________________
6. Stock or stock options in a company or supplier
(The following conflicts were disclosed):

_________________________________________________

_________________________________________________
7. Research support from a company or supplier as Principal Investigator
(The following conflicts were disclosed):

_________________________________________________

_________________________________________________
8. Other financial or material support from a company or supplier
(The following conflicts were disclosed):

_________________________________________________

_________________________________________________
9. Royalties, financial or material support from publishers
(The following conflicts were disclosed):

_________________________________________________

_________________________________________________
10. Board member or committee appointments for a society
(The following conflicts were disclosed):

_________________________________________________

_________________________________________________

Author Information

Author Name (Print or Type) Signature Date
__________________________ __________________________ ____________

 

Conflict of Interest Statement for Publication

The following information will be published on the first page of each manuscript. Please check one of the following:

☐ 1. No benefits or funds were received in support of this study.
☐ 2. Benefits or funds were received in partial or total support of the research material described in this article. These benefits and/or support were received from:

_________________________________________________

_________________________________________________

Signature of Each Author

Author Signature Date
__________________________ __________________________ ____________
__________________________ __________________________ ____________
__________________________ __________________________ ____________

Manuscript Number (if available): ______________________

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