AuthorAgreementandDisclosureforEvidence-BasedPractice
Nomanuscriptswillbepublishedwithoutanauthordisclosureformsubmittedforeachauthoringparty.
Primary/Corresponding Author First Name:
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Primary/Corresponding Author Last Name:
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Credentials:
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Today’s Date: Click here to enter a date.
Organization:
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Author E-mail:
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Author Phone Number:
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Title of Manuscript:
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Project Type (select one):
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Doyouhaveco-authorsonthismanuscript?Ifyes,eachauthormustfilloutthisformindividually.Additionalcopiesofthisformhavebeenprovidedattheendofthisdocument.PleasesubmitallformstogetherinonePDFfile.
☐Yes☐No
AUTHORSHIPSTATEMENT
Allauthorsarerequiredtodiscloseaccuratelytheircontributioninthecreationofthismanuscript.IndividualsmustmeettheeachofthecriterionbelowtoqualifyforauthorshipinaccordancewiththeInternationalCommitteeofMedicalJournalEditors(ICMJE)standards.Formoreinformationonthispolicy,pleasevisit.icmje.org/recommendations/browse/roles- and-responsibilities/defining-the-role-of-authors-and-contributors.html.
Haveyoumadesubstantialcontributionstothecontentofthismanuscript?Thiscanbeintheformofconceptanddesigncontributionorthroughthegathering,analysisorinterpretationofthedata.
☐Yes☐No
Didyoueitherdraftthismanuscriptorcriticallyreviseimportantcontent?
☐Yes☐No
Didyouapproveofthefinalversionofthemanuscriptpriortosubmission?
☐Yes☐No
Doyouagreetobeaccountableforthecontentinthismanuscriptandanyquestions,ifraised,relatedtoaccuracyorintegrityoftheinformationpresentedwillbeappropriatelyinvestigatedandresolved?
☐Yes☐No
CONFLICTOFINTEREST
Disclosureoffinancialrelationshipswithin3yearsofthedateofthisformandwithintheforeseeablefuture(Pleasecheckallthatapply).
Haveyouoranimmediatefamilymember(parent,sibling,spouse,child)hadafinancialrelationshipwithoranycommercialentitythatmayhaveadirectinterestinthesubjectmatterofthisarticle?Ifyes,pleaseexplain.
☐Yes☐No
Ifyes,pleaseindicatethenatureoftherelationship.(Pleasecheckalltypesthatapply.PleaseselectN/Aifnoneapply).
☐ Consultant or Advisory Board
☐ Employment
☐ Honorarium
☐ ManuscriptPreparationAssistance
☐ Partnership
☐Receiptofequipmentor supplies
☐ Researchgrantsorsupport
☐ Speakers'Bureaus
☐ Stock/BondHoldings (excludingmutualfunds)
☐Otherfinancialsupport
☐ N/A
IfyoucheckedanythingotherthanN/Aabove,pleaseindicatethenamesoftheorganizationswithwhichyouhavefinancialrelationshipsorinterests,andthespecifictopicareasthatcorrespondtoeachrelationship.
Organizations
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Ifyouchecked"Speakers'Bureaus"underSection2,pleasecheckallofthefollowingthatapply.Ifnoneapply,pleaseselectN/A.
Didyouparticipateincompany-providedspeakertraining?
☐Yes☐No☐N/A
Didthecompanyprovideyouwithslidesofapresentationinwhichyouweretrainedasaspeaker?
☐Yes☐ No ☐ N/A
Haveyoureceivedcompensationfromthecompanyfortraining,travel,speakingoranotherreason?
☐Yes ☐No
If yes, please specify:
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Ifyouchecked"ManuscriptPreparationAssistance"underSection2,pleaseanswerthefollowingquestions:
- Wasanyassistanceprovidedbyamedicalcommunicationscompanyorprofessionalwriter/editor?
☐ Yes ☐ No ☐ N/A
If yes, who provided the assistant and who paid for it?
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- Didanythirdparty(pharmaceuticalcompany,publicrelationsfirmorothercommercialentitycontributeorsponsorthecreationofyourarticleeitherdirectlyorindirectly?
☐ Yes☐No
- Wasthetopicofyourmanuscriptsuggestedbyamedicalcommunicationscompany,entityproducinghealthcaregoodsorservices,oranadvisorypanelthatreceivessupport(forexample,educationalgrants)fromacommercialentity?
☐ Yes☐ No
- Doesyourmanuscriptincorporate,orisanypartbasedonmaterialsprovidedbyacommercialentity(e.g.brochures,pamphlets,advertisements,sponsoredwebmaterial)?
☐ Yes ☐No
- Doesyourmanuscriptincorporateanyinformationordataobtainedfromacommercialspeakeronbehalfofacommercialentity?
☐ Yes☐
Note:Ourconflictofinterestpolicyprecludesusfromconsideringmanuscriptssponsoreddirectlyorindirectlybyapharmaceuticalcompany,medicaleducationcompany,orothercommercialentity,orthosewrittenbyanauthorwhohasafinancialrelationshipwithorinterestinanycommercialentitythatmayhaveaninterestinthesubjectmatterofthearticle.IfyoudevelopnewfinancialrelationshipswithorinterestsinarelevantcommercialentityafteryouhavecompletedthisAuthor AgreementandDisclosureformandsubmittedyourmanuscript,butpriortopublication,pleaseupdateyourformandsendittooureditorialoffice(seebelow).
Changesinsuchaffiliationsmightprecludeyourpaperfrompublication.IacknowledgethatthisarticleisthesolecopyrightofFPINandwillnotbesubmittedtoanyotherpublications.Thisarticleisnotaduplicateofanyotherpreviouslywrittenmanuscript.IacknowledgeFPINcomplieswiththeInternationalCommitteeofMedicalJournalsUniformRequirementsformanuscriptsviewableat publication-ethics/.
☐ Bycheckingthisbox,IacknowledgeIhavereadtheFPINpolicyonfulldisclosure.IfIhaveindicatedafinancialrelationshiporinterest,Iunderstandthatthisinformationwillbereviewedtodeterminewhetherthisrelationshipprecludesmyparticipation,andthatImaybeaskedtoprovideadditionalinformation.Iunderstandthatfailureorrefusaltodisclose,falsedisclosureorinabilitytoresolveconflictsofinterestwilldisqualifymefromparticipationinthisactivity.Irepresentandwarrantthattheinformationprovidedbymeinthisformiscomplete,trueandaccurate.
Electronic Signature (Please enter First, Middle Initial and Last Name)
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