Disclosure of Financial Interest
Manuscript No.
Manuscript Title:
Every author on the manuscript is required to complete this form
A conflict-of-interest is defined as a set of conditions in which professional judgment concerning a primary interest,
such as the validity of research, may be influenced by a secondary interest, such as financial gain. As such, a
conflict-of-interest is a condition, not a behavior -- being determined by circumstances, not outcome. A conflict
exists not only when judgment has been clearly influenced. It also exists when judgment might be influenced or
might be perceived to be influenced. That is, a conflict exists before any actual breach of trust, and irrespective of
whether a breach of trust actually occurs.
When submitting a manuscript to the Journal, authors are required to disclose any financial relationship with a
biotechnology manufacturer, a pharmaceutical manufacturer, or other commercial entity that has an interest in the
subject matter or materials discussed in the manuscript. The Journal’s policy on personal financial interests also
embraces money received in the names of the children, spouse, and partner (i.e., life companion) of an author.
The Journal requires authors to list receipt of more than $10,000 per company per year in any one of the 3 years
preceding submission of this manuscript (money received for different services to any one company should be
aggregated). Symbols such as “>” should not be used; instead, the dollar amount should be listed. Because the
threshold of $10,000 is necessarily arbitrary, the Journal also encourages authors to list lesser amounts. In addition,
the Journal requires authors to list any relationships covered under “Other Relationships”.
.
1.
Personal Financial Interests
Category of Financial Interest
1. Employment by commercial
entity that sponsored the study
2. Consultancies
3. Advisory board
4. Lecture fees paid by a
commercial sponsor (per company
per year for the last 3 years)
5. Expert witness for a commercial
sponsor
6. Industry-sponsored grants
(received or pending)
7. Patents received or pending
8. Royalties from a commercial
sponsor
If you have had any of the listed relationships with a commercial entity that
has an 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. Please consider the past 3 years through the
present when answering this question. Provide details for "yes" responses
below.
No
Yes (Give dates and amounts)
9. Stock ownership or options (other
than mutual funds)
10. Other
If you answered “yes” to any of the financial interests in the preceding list, you meet the Journal’s definition for
conflict of interest, which must be disclosed. An example of a statement based on disclosures from all co-authors is
the following:
Conflict of Interest Statement
JD has been reimbursed by Novartis for attending several conferences; RT has participated
as a speaker in scientific meetings or courses organized and financed by various
pharmaceutical companies (GlaxoSmithKline, Wyeth, AstraZeneca); FD received $13,000
in 2002 for serving on an advisory board for Merck, Sharpe & Dohme; NF serves as a
consultant to Pfizer; GF received $7,000 in 2002 and $6,000 in 2001 for speaking at
conferences sponsored by Boehringer Ingelheim; RK received $255,000 in 2001 and 2002
from Bristol-Myers Squibb as research grants for participating in multi-center clinical
trials; TF is an employee of Pharmacia; CK is chairman of the Foundation for Sepsis
Research, some of whose activities have been financed by Lilly; BR’s institution has
received an unrestricted educational grant from AstraZeneca; BE’s spouse has shares in
Wyeth. JG has no declared conflict of interest.
Each author must draft a statement of financial disclosure related to him or herself here: ………………………
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2. Institutional Financial Interest
Are you aware whether your institution or employer has a financial relationship with a commercial entity that has an
interest in the subject matter or materials discussed in this manuscript?
___ No
___ Yes, please describe below and provide additional detail in a cover letter in the "Author Comments" area on the
ScholarOne website if necessary
I attest that the information on this form is true:
Author: Name (please type or print) ______________________________________ Date __________________
All of the forms from each and every author need to be uploaded online and submitted with the
manuscript at the time of submission. You can also choose to fax these forms to the Peer Review
Office at 212-315-8613/8616 or email them to forms@thoracic.org. If you have questions or
problems, please contact Karin Beehler at 212-315-8626 or kbeehler@thoracic.org.