DISCLOSURE FORM
DISCLOSURE FORM CNS Spectrums Date:
Author Name: Manuscript Title:
Check all that apply (please check at least one of these boxes) I or a related party do not have any sort of financial relationship(s) to disclose I or a related party currently have or have had a financial relationship with a financially interested entity for the past 12 months (check all that apply) Name of the Institution (e.g. Pharmaceutical Company, Medical Supply Company, etc.)
Type of activity with the institution: · Consultant/Advisor · Employee · Independent Contractor · Officer/Director · Fiduciary role · Research Support (Grants, etc.) · Other (Speaker’s Bureau, etc.)
Type of compensation received from the institution, if any: · Consulting fees · Honoraria · Salaries, Director fees, etc. · Gifts, gratuities, etc. · Other forms of ownership · Research support (Grants, etc.) · Other (Speaker’s fee, etc.)
Do you own stocks, stock options, or other forms of ownership in any commercial entity that would appear to be affected by the conduct or outcome of the program? · Ownership · Stocks · Gifts/gratuities. · Other
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. **If you run out of room for your disclosures on this page, please include the rest of them on page 2 of this document. If this applies for you, please sign the second page as well. List the names of the proprietary entities producing health care goods or services (commercial interests). ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ If you marked any conflict, will it affect your presentation?
Yes
No
I intend to reference unlabeled/unapproved/experimental and/or investigational (non FDA-approved) uses of drugs or products in my presentation, and will disclose this to the audience (specify drugs(s) or products(s) by name for which unlabeled use in my discussion): ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
_____________________________ _______________________________
____________
Signature
Date
Print Name
** Each author must complete this form and send to the submitting author as a PDF. It is the responsibility of the submitting author to upload all completed forms with the manuscript in the online submission system.
Complete disclosure form, sign, and submit to [email protected].
Page 1 of 2
Further disclosures: Name of the Institution (e.g. Pharmaceutical Company, Medical Supply Company, etc.)
Type of activity with the institution: · Consultant/Advisor · Employee · Independent Contractor · Officer/Director · Fiduciary role · Research Support (Grants, etc.) · Other (Speaker’s Bureau, etc.)
Type of compensation received from the institution, if any: · Consulting fees · Honoraria · Salaries, Director fees, etc. · Gifts, gratuities, etc. · Other forms of ownership · Research support (Grants, etc.) · Other (Speaker’s fee, etc.)
Do you own stocks, stock options, or other forms of ownership in any commercial entity that would appear to be affected by the conduct or outcome of the program? · Ownership · Stocks · Gifts/gratuities. · Other
11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.
_____________________________ _______________________________
____________
Signature
Date
Print Name
Complete disclosure form, sign, and submit to [email protected].
Page 2 of 2
Author Name: Manuscript Title:
Check all that apply (please check at least one of these boxes) I or a related party do not have any sort of financial relationship(s) to disclose I or a related party currently have or have had a financial relationship with a financially interested entity for the past 12 months (check all that apply) Name of the Institution (e.g. Pharmaceutical Company, Medical Supply Company, etc.)
Type of activity with the institution: · Consultant/Advisor · Employee · Independent Contractor · Officer/Director · Fiduciary role · Research Support (Grants, etc.) · Other (Speaker’s Bureau, etc.)
Type of compensation received from the institution, if any: · Consulting fees · Honoraria · Salaries, Director fees, etc. · Gifts, gratuities, etc. · Other forms of ownership · Research support (Grants, etc.) · Other (Speaker’s fee, etc.)
Do you own stocks, stock options, or other forms of ownership in any commercial entity that would appear to be affected by the conduct or outcome of the program? · Ownership · Stocks · Gifts/gratuities. · Other
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. **If you run out of room for your disclosures on this page, please include the rest of them on page 2 of this document. If this applies for you, please sign the second page as well. List the names of the proprietary entities producing health care goods or services (commercial interests). ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ If you marked any conflict, will it affect your presentation?
Yes
No
I intend to reference unlabeled/unapproved/experimental and/or investigational (non FDA-approved) uses of drugs or products in my presentation, and will disclose this to the audience (specify drugs(s) or products(s) by name for which unlabeled use in my discussion): ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
_____________________________ _______________________________
____________
Signature
Date
Print Name
** Each author must complete this form and send to the submitting author as a PDF. It is the responsibility of the submitting author to upload all completed forms with the manuscript in the online submission system.
Complete disclosure form, sign, and submit to [email protected].
Page 1 of 2
Further disclosures: Name of the Institution (e.g. Pharmaceutical Company, Medical Supply Company, etc.)
Type of activity with the institution: · Consultant/Advisor · Employee · Independent Contractor · Officer/Director · Fiduciary role · Research Support (Grants, etc.) · Other (Speaker’s Bureau, etc.)
Type of compensation received from the institution, if any: · Consulting fees · Honoraria · Salaries, Director fees, etc. · Gifts, gratuities, etc. · Other forms of ownership · Research support (Grants, etc.) · Other (Speaker’s fee, etc.)
Do you own stocks, stock options, or other forms of ownership in any commercial entity that would appear to be affected by the conduct or outcome of the program? · Ownership · Stocks · Gifts/gratuities. · Other
11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.
_____________________________ _______________________________
____________
Signature
Date
Print Name
Complete disclosure form, sign, and submit to [email protected].
Page 2 of 2
