author disclosure form - AWS
AUTHOR DISCLOSURE FORM Manuscript Title: _______________________________________________________________________________________________________
Each author must read and complete this form—even if you have nothing to disclose. The corresponding author should collect a completed form from each author and submit all signed forms with the manuscript. For more information about the Journal’s disclosure policy, refer to the “Author Disclosure” section of the Instructions for Authors available online at www.ajmc.com. The information you provide will only be used to create disclosure statements to be published with your paper.
1. Personal Potential Conflict
If within the past 12 months you have had any relationship with an entity that has a financial interest in the subject matter discussed in this manuscript, check the appropriate “yes” box below. If you do not have a listed relationship, check the appropriate “no” box.
No
Yes
Please describe potential conflicts of interest below and provide additional detail in a cover letter, if necessary.
Board membership Consultancies or paid advisory boards Employment Expert testimony Grants pending Grants received Honoraria Lecture fees for speaking at the invitation of a commercial sponsor Meeting/conference attendance Patents pending Patents received Receipt of payment for involvement in the preparation of this manuscript Royalties Stock ownership Other (specify) 2. Institutional Conflicts of Interest
Does your academic institution or employer have any financial interest in or financial conflict with the subject matter discussed in the manuscript? No
Yes
If yes, please describe below and provide additional detail in a cover letter, if necessary.
Full Name & Degree (please print): ___________________________________________________________________________________ Signature: ___________________________________________________________________________
Date: ______________________
PLEASE RETURN THE COMPLETED FORM BY E-MAIL TO [email protected]
Each author must read and complete this form—even if you have nothing to disclose. The corresponding author should collect a completed form from each author and submit all signed forms with the manuscript. For more information about the Journal’s disclosure policy, refer to the “Author Disclosure” section of the Instructions for Authors available online at www.ajmc.com. The information you provide will only be used to create disclosure statements to be published with your paper.
1. Personal Potential Conflict
If within the past 12 months you have had any relationship with an entity that has a financial interest in the subject matter discussed in this manuscript, check the appropriate “yes” box below. If you do not have a listed relationship, check the appropriate “no” box.
No
Yes
Please describe potential conflicts of interest below and provide additional detail in a cover letter, if necessary.
Board membership Consultancies or paid advisory boards Employment Expert testimony Grants pending Grants received Honoraria Lecture fees for speaking at the invitation of a commercial sponsor Meeting/conference attendance Patents pending Patents received Receipt of payment for involvement in the preparation of this manuscript Royalties Stock ownership Other (specify) 2. Institutional Conflicts of Interest
Does your academic institution or employer have any financial interest in or financial conflict with the subject matter discussed in the manuscript? No
Yes
If yes, please describe below and provide additional detail in a cover letter, if necessary.
Full Name & Degree (please print): ___________________________________________________________________________________ Signature: ___________________________________________________________________________
Date: ______________________
PLEASE RETURN THE COMPLETED FORM BY E-MAIL TO [email protected]
