Date: ___________________________
Your Name: ___________________________
Manuscript Title: ___________________________
Manuscript Number (if known): ___________________________
In the interest of transparency, we ask you to disclose all relationships/activities/interests listed below that are related to the content of your manuscript. “Related” means any relation with for-profit or not-for-profit third parties whose interests may be affected by the content of the manuscript. Disclosure represents a commitment to transparency and does not necessarily indicate a bias. If you are in doubt about whether to list a relationship/activity/interest, it is preferable that you do so.
The author’s relationships/activities/interests should be defined broadly. For example, if your manuscript pertains to the epidemiology of hypertension, you should declare all relationships with manufacturers of antihypertensive medication, even if that medication is not mentioned in the manuscript.
In item #1 below, report all support for the work reported in this manuscript without time limit. For all other items, the time frame for disclosure is the past 36 months.
| # | Name all entities with whom you have this relationship or indicate none (add rows as needed) | Specifications/Comments (e.g., if payments were made to you or to your institution) | |
|---|---|---|---|
| Time frame: past 36 months | |||
| 1 | All support for the present manuscript (e.g., funding, provision of study materials, medical writing, article processing charges, etc.) No time limit for this item | ☐ None | |
| 2 | Grants or contracts from any entity (if not indicated in item #1 above). | ☐ None | |
| 3 | Royalties or licenses. | ☐ None | |
| 4 | Consulting fees. | ☐ None | |
| 5 | Payment or honoraria for lectures, presentations, or educational events. | ☐ None | |
| 6 | Payment for expert testimony. | ☐ None | |
| 7 | Support for attending meetings and/or travel. | ☐ None | |
| 8 | Patents planned, issued or pending. | ☐ None | |
| 9 | Participation on a Data Safety Monitoring Board or Advisory Board. | ☐ None | |
| 10 | Leadership or fiduciary role in board, society, committee, or advocacy group. | ☐ None | |
| 11 | Stock or stock options. | ☐ None | |
| 12 | Receipt of equipment, materials, gifts or other services. | ☐ None | |
| 13 | Other financial or non-financial interests. | ☐ None | |
Please place an “X” next to the statement below to indicate your agreement:
☐ I certify that I have answered every question and have not altered the wording of any of the questions on this form.