ICMJE Form For Disclosure of Potential Conflicts of Interest
ICMJE 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 six parts.
1.
Identifying information.
2.
3.
4.
Intellectual Property.
This section asks about patents and copyrights, whether pending, issued, licensed and/or receiving royalties.
5.
Definitions.
Entity: government agency, foundation, commercial sponsor,
academic institution, etc.
Grant: A grant from an entity, generally [but not always] paid to your
organization
Personal Fees: Monies paid to you for services rendered, generally
honoraria, royalties, or fees for consulting , lectures, speakers bureaus,
expert testimony, employment, or other affiliations
Non-Financial Support: Examples include drugs/equipment
supplied by the entity, travel paid by the entity, writing assistance,
administrative support, etc.
Bailey
Identifying Information
3. Date
Michael
Bailey
23-February-2015
No
Yes
Rinaldo Bellomo
5. Manuscript Title
14-15236
Section 2.
Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for
any aspect of the submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation,
statistical analysis, etc.)?
Section 3.
Yes
No
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 publication.
Are there any relevant conflicts of interest?
Section 4.
Yes
No
Do you have any patents, whether planned, pending or issued, broadly relevant to the work?
Bailey
Yes
No
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?
Yes, the following relationships/conditions/circumstances are present (explain below):
No other relationships/conditions/circumstances that present a potential conflict of interest
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.
Section 6.
Disclosure Statement
Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box
below.
Bailey
1.
Identifying information.
2.
3.
4.
Intellectual Property.
This section asks about patents and copyrights, whether pending, issued, licensed and/or receiving royalties.
5.
Definitions.
Entity: government agency, foundation, commercial sponsor,
academic institution, etc.
Grant: A grant from an entity, generally [but not always] paid to your
organization
Personal Fees: Monies paid to you for services rendered, generally
honoraria, royalties, or fees for consulting , lectures, speakers bureaus,
expert testimony, employment, or other affiliations
Non-Financial Support: Examples include drugs/equipment
supplied by the entity, travel paid by the entity, writing assistance,
administrative support, etc.
Bellomo
Identifying Information
3. Date
Rinaldo
Bellomo
23-February-2015
Yes
No
5. Manuscript Title
14-15236
Section 2.
Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for
any aspect of the submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation,
statistical analysis, etc.)?
Section 3.
Yes
No
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 publication.
Are there any relevant conflicts of interest?
Section 4.
Yes
No
Do you have any patents, whether planned, pending or issued, broadly relevant to the work?
Bellomo
Yes
No
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?
Yes, the following relationships/conditions/circumstances are present (explain below):
No other relationships/conditions/circumstances that present a potential conflict of interest
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.
Section 6.
Disclosure Statement
Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box
below.
Bellomo
1.
Identifying information.
2.
3.
4.
Intellectual Property.
This section asks about patents and copyrights, whether pending, issued, licensed and/or receiving royalties.
5.
Definitions.
Entity: government agency, foundation, commercial sponsor,
academic institution, etc.
Grant: A grant from an entity, generally [but not always] paid to your
organization
Personal Fees: Monies paid to you for services rendered, generally
honoraria, royalties, or fees for consulting , lectures, speakers bureaus,
expert testimony, employment, or other affiliations
Non-Financial Support: Examples include drugs/equipment
supplied by the entity, travel paid by the entity, writing assistance,
administrative support, etc.
Cooper
Identifying Information
3. Date
D. James
Cooper
23-February-2015
No
Yes
Rinaldo Bellomo
5. Manuscript Title
14-15236
Section 2.
Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for
any aspect of the submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation,
statistical analysis, etc.)?
Section 3.
Yes
No
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 publication.
Are there any relevant conflicts of interest?
Section 4.
Yes
No
Do you have any patents, whether planned, pending or issued, broadly relevant to the work?
Cooper
Yes
No
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?
Yes, the following relationships/conditions/circumstances are present (explain below):
No other relationships/conditions/circumstances that present a potential conflict of interest
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.
Section 6.
Disclosure Statement
Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box
below.
Cooper
1.
Identifying information.
2.
3.
4.
Intellectual Property.
This section asks about patents and copyrights, whether pending, issued, licensed and/or receiving royalties.
5.
Definitions.
Entity: government agency, foundation, commercial sponsor,
academic institution, etc.
Grant: A grant from an entity, generally [but not always] paid to your
organization
Personal Fees: Monies paid to you for services rendered, generally
honoraria, royalties, or fees for consulting , lectures, speakers bureaus,
expert testimony, employment, or other affiliations
Non-Financial Support: Examples include drugs/equipment
supplied by the entity, travel paid by the entity, writing assistance,
administrative support, etc.
Kaukonen
Identifying Information
3. Date
Kirsi-Maija
Kaukonen
22-February-2015
No
Yes
Rinaldo Bellomo
5. Manuscript Title
14-15236
Section 2.
Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for
any aspect of the submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation,
statistical analysis, etc.)?
Yes
No
If yes, please fill out the appropriate information below. If you have more than one entity press the "ADD" button to add a row.
Excess rows can be removed by pressing the "X" button.
Name of Institution/Company
Section 3.
Comments
Grant for Clinical Researcher Career.
Ended 31 Aug, 2014
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 publication.
Are there any relevant conflicts of interest?
Section 4.
Yes
No
Do you have any patents, whether planned, pending or issued, broadly relevant to the work?
Kaukonen
Yes
No
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?
Yes, the following relationships/conditions/circumstances are present (explain below):
No other relationships/conditions/circumstances that present a potential conflict of interest
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.
Section 6.
Disclosure Statement
Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box
below.
Dr. Kaukonen reports grant support from The Academy of Finland during the conduct of the study.
Kaukonen
1.
Identifying information.
2.
3.
4.
Intellectual Property.
This section asks about patents and copyrights, whether pending, issued, licensed and/or receiving royalties.
5.
Definitions.
Entity: government agency, foundation, commercial sponsor,
academic institution, etc.
Grant: A grant from an entity, generally [but not always] paid to your
organization
Personal Fees: Monies paid to you for services rendered, generally
honoraria, royalties, or fees for consulting , lectures, speakers bureaus,
expert testimony, employment, or other affiliations
Non-Financial Support: Examples include drugs/equipment
supplied by the entity, travel paid by the entity, writing assistance,
administrative support, etc.
Pilcher
Identifying Information
3. Date
David
Pilcher
23-February-2015
No
Yes
Rinaldo Bellomo
5. Manuscript Title
14-15236
Section 2.
Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for
any aspect of the submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation,
statistical analysis, etc.)?
Section 3.
Yes
No
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 publication.
Are there any relevant conflicts of interest?
Section 4.
Yes
No
Do you have any patents, whether planned, pending or issued, broadly relevant to the work?
Pilcher
Yes
No
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?
Yes, the following relationships/conditions/circumstances are present (explain below):
No other relationships/conditions/circumstances that present a potential conflict of interest
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.
Section 6.
Disclosure Statement
Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box
below.
Pilcher