Nejme Form For Disclosure of Potential Conflicts of Interest

ICMJE Form for Disclosure of Potential Conflicts of Interest
Instructions
The purpose of this form is to provide readers of your manuscript with information about your other interests that could
influence how they receive and understand your work. The form is designed to be completed electronically and stored
electronically. It contains programming that allows appropriate data display. Each author should submit a separate
form and is responsible for the accuracy and completeness of the submitted information. The form is in four parts.
1.
Identifying information.
Enter your full name. If you are NOT the corresponding author please check the box "no" and a space to enter the name of
the corresponding author in the space that appears. Provide the requested manuscript information. Double-check the
manuscript number and enter it.
2.
The work under consideration for publication.

This section asks for information about the work that you have submitted for publication. The time frame for this reporting
is that of the work itself, from the initial conception and planning to the present. The requested information is about
resources that you received, either directly or indirectly (via your institution), to enable you to complete the work. Checking
"No" means that you did the work without receiving any financial support from any third party -- that is, the work was
supported by funds from the same institution that pays your salary and that institution did not receive third-party funds
with which to pay you. If you or your institution received funds from a third party to support the work, such as a
government granting agency, charitable foundation or commercial sponsor, check "Yes". The complete the appropriate
boxes to indicate the type of support and whether the payment went to you, or to your institution, or both.
3.
Relevant financial activities outside the submitted work.

This section asks about your financial relationships with entities in the bio-medical arena that could be perceived to
influence,or that give the appearance of potentially influencing, what you wrote in the submitted work. You should
disclose interactions with ANY entity that could be considered broadly relevant to the work. For example, if your article is
about testing an epidermal growth factor receptor (EGFR) antagonist in lung cancer, you should report all associations with
entities pursuing diagnostic or therapeutic strategies in cancer in general, not just in the area of EGFR or lung cancer.
Report all sources of revenue paid (or promised to be paid) directly to you or your institution on your behalf over the 36
months prior to submission of the work. This should include all monies from sources with relevance to the submitted work,
not just monies from the entity that sponsored the research. Please note that your interactions with the work's sponsor
that are outside the submitted work should also be listed here. If there is any question, it is usually better to disclose a
relationship than not to do so.
For grants you have received for work outside the submitted work, you should disclose support ONLY from entities that
could be perceived to be affected financially by the published work, such as drug companies, or foundations supported by
entities that could be perceived to have a financial stake in the outcome. Public funding sources, such as government
agencies, charitable foundations or academic institutions, need not be disclosed. For example, if a government agency
sponsored a study in which you have been involved and drugs were provided by a pharmaceutical company, you need
only list the pharmaceutical company.
4.
Other relationships.
Use this section to report other relationships or activities that readers could perceive to have influenced, or that give the
appearance of potentially influencing, what you wrote in the submitted work.
Heinecke

Section 1.
Identifying Information
1. Given Name (First Name)
2. Surname (Last Name)
3. Effective Date (07-August-2008)
Jay
Heinecke
01-November-2010
4. Are you the corresponding author?
Yes
No
5. Manuscript Title
HDL and Cardiovascular Disease Risk Time for a New Approach?

6. Manuscript Identifying Number (if you know it)
10-12520
Section 2.
The Work Under Consideration for Publication
Did you or your institution at any time receive payment or services from a third party for any aspect of the submitted work
(including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc)?
Complete each row by checking No or providing the requested information. If you have more than one relationship click the
Add button to add a row. Excess rows can be removed by clicking the X button.

Type
No
Money Money to
Paid
Your
to You Institution*
1. Grant
Name of Entity
NIH
Comments**
ADD
2. Consulting fee or honorarium
ADD
3. Support for travel to meetings for

the study or other purposes
ADD
4. Fees for participation in review

activities such as data monitoring
boards, statistical analysis, end
point committees, and the like
ADD
5. Payment for writing or reviewing

the manuscript
ADD
6. Provision of writing assistance,

medicines, equipment, or
administrative support
Heinecke

Type
No
Money Money to
Paid
Your
to You Institution*
Name of Entity
Comments**
ADD
7. Other
ADD
* This means money that your institution received for your efforts on this study.
** Use this section to provide any needed explanation.
Section 3.
Relevant financial activities outside the submitted work.
Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount
of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by
clicking the "Add +" box. You should report relationships that were present during the 36 months prior to submission.
Complete each row by checking No or providing the requested information. If you have more than one relationship click the
Add button to add a row. Excess rows can be removed by clicking the X button.
Relevant financial activities outside the submitted work

Type of Relationship (in
alphabetical order)
1. Board membership
No
Money Money to
Paid to
Your
You Institution*
Entity
Comments
ADD
2. Consultancy
Merck
2. Consultancy
Scherring Plough
2. Consultancy
Amgen
2. Consultancy
GSK
2. Consultancy
Bristol Meyer Squibb
2. Consultancy
Corcept
ADD
3. Employment
ADD
4. Expert testimony
ADD
Heinecke

Relevant financial activities outside the submitted work
Type of Relationship (in
alphabetical order)
No
Money Money to
Paid to
Your
You Institution*
5. Grants/grants pending
Entity
Merck
Comments
Award over 2 years for
investigator-initiated
research
ADD
6. Payment for lectures including

service on speakers bureaus
Merck
ADD
7. Payment for manuscript
preparation
ADD
8. Patents (planned, pending or
issued)
ADD
9. Royalties
ADD
10. Payment for development of
educational presentations
ADD
11. Stock/stock options
Insilicos
Insilicos is not publicly

traded and there is no
known market for the
equity of the company.
The options may or may
not have any present
value.
ADD
12. Travel/accommodations/
meeting expenses unrelated to
activities listed**
ADD
13. Other (err on the side of full

disclosure)
Cleveland Heart Labs
The Cleveland Heart Labs

has a licensing
agreement with the
University of Washington
based on the patent
(7749729) noted below.
ADD
* This means money that your institution received for your efforts.
** For example, if you report a consultancy above there is no need to report travel related to that consultancy on this line.
Heinecke

Section 4.
Other relationships
Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of
potentially influencing, what you wrote in the submitted work?
No other relationships/conditions/circumstances that present a potential conflict of interest
Yes, the following relationships/conditions/circumstances are present (explain below):
Jay Heinecke, John Oram and the University of Washington hold a patent (7749729) that relates to diagnostic tests for
measuring the quantity of one or more HDL oxidation products. Such products may be useful in evaluating the risk for
developing cardiovascular disease.
At the time of manuscript acceptance, journals will ask authors to confirm and, if necessary, update their disclosure statements.
On occasion, journals may ask authors to disclose further information about reported relationships.
Hide All Table Rows Checked 'No'
SAVE
Evaluation and Feedback

Please visit http://www.icmje.org/cgi-bin/feedback to provide feedback on your experience with completing this form.
Heinecke

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ICMJE Form for Disclosure of Potential Conflicts of Interest

The work under consideration for publication.

Relevant financial activities outside the submitted work.

ICMJE Form for Disclosure of Potential Conflicts of Interest

1. Given Name (First Name)

2. Surname (Last Name)

3. Effective Date (07-August-2008)

4. Are you the corresponding author?

HDL and Cardiovascular Disease Risk Time for a New Approach?

The Work Under Consideration for Publication

The Work Under Consideration for Publication

2. Consulting fee or honorarium

3. Support for travel to meetings for

4. Fees for participation in review

5. Payment for writing or reviewing

6. Provision of writing assistance,

ICMJE Form for Disclosure of Potential Conflicts of Interest

Relevant financial activities outside the submitted work.

Relevant financial activities outside the submitted work

Bristol Meyer Squibb

ICMJE Form for Disclosure of Potential Conflicts of Interest

6. Payment for lectures including

11. Stock/stock options

Insilicos is not publicly

13. Other (err on the side of full

Cleveland Heart Labs

The Cleveland Heart Labs

ICMJE Form for Disclosure of Potential Conflicts of Interest

Hide All Table Rows Checked 'No'

Evaluation and Feedback

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