Journal of Foot & Ankle Surgery: Authors’ Conflict of Interest Disclosure

(Do Not Return This First Page) (rev. 09-2010)

Actual or potential conflicts of interest may have an impact on all participants in the process of publication of a medical journal. An actual or potential conflict regarding publication occurs when a competing interest (financial, competitive or otherwise) may influence (intentionally or not) the interests of safety, veracity, or interpretation of data and results.

Not identifying these conflicts may bring actual or potential harm to patients, cause embarrassment to the journal, reviewers and the American College of Foot & Ankle Surgeons (ACFAS), and bring disrepute to the investigators and others involved in the editorial process. To avoid this, all authors must disclose actual or potential conflicts related to all aspects of their manuscript. This includes any actual or potential competing interest related to the design, conduct, and interpretation of the data. A disclosure statement will accompany all articles published in JFAS.

The following competing interests or relationships must be disclosed, including those of persons related to the authors such as spouses, dependent children, or adult children employed by a sponsor of the research, or any other relationship involving the actual or potential sharing of income or assets. The following are referred to as Required Disclosures:

  1. Leadership Position: Employment or service as an officer or board member for an entity having an investment, licensing, or other commercial interest in the subject matter under consideration
  2. Consultant/Advisory Role: Arrangements with an entity having an investment, licensing, or other commercial interest in the subject matter under consideration if performed or payments made within two years or anticipated to be paid in the future
  3. Stock Ownership: Any ownership interest including stock, options, and warrants in any publicly traded or privately held company if the company is an entity having an investment, licensing, or other commercial interest in the subject matter under consideration, except an interest of less than 5% in a publicly traded fund not controlled by the covered individual
  4. Honoraria: Honoraria for specific speeches, seminar presentations, or appearances when paid to the covered individual by an entity (or agent of the entity) having an investment, licensing, or other commercial interest in the subject mater under consideration and when provided within two years or anticipated to be paid in the future
  5. Research Funding: Payments associated with the conduct of the clinical research project in question if provided by the trial sponsor or agent of the entity
  6. Expert Testimony: Provision of expert testimony related to the subject matter under question
  7. Other Compensation: Trips, travel, gifts, or other in-kind payments not directly related to specific research activities (if not disclosed as related to research related funding) if received from an entity having an investment, licensing, or other commercial interest in the subject matter under consideration and when received within two years of the activity or subject matter in question or anticipated to be received within one year after submission. Aggregate amounts of less than $500 per payor (including its agents) are excluded from disclosure requirements.

(Below, please find the portion of this disclosure form that all authors must complete and return to the Journal’s Editor. Return information is present at the bottom of the next page. Return only the following page.)

Author’s Conflict of Interest Disclosure Form(rev. 09-2010)

All authors must complete, execute, and return only this page to The Journal of Foot & Ankle Surgery.

Manuscript Number and Title:Authors (please print):

  1. Attestation of Investigator Independence/Accountability: Did the authors have full access to all study data, take full responsibility for the accuracy of the data analysis, and have authority over manuscript preparation and decisions to submit the manuscript for publication?

 Yes

 No(Please describe below and on a separate sheet if necessary.)

  1. Institutional Conflicts of Interest: Are you aware that any of the authors’ academic institutions or employers has any financial interest in or a financial conflict with the subject matter or materials discussed in this manuscript?

 No

 Yes (Please describe below and on a separate sheet if necessary.)

  1. Authors’ Financial Conflict of Interest

Category of Potential
Conflict / Authors having any of the Required Disclosures described on page 1 must write the author’s name and the dollar amount (if any) of the disclosure in the appropriate “yes” box below. If none of the authors has a listed relationship, check the appropriate “no” box. Provide explanations on a separate sheet, and insert a disclosure statement in the manuscript. Please consider the last 2 years through the next 12 months when answering this question.
No / Yes
A. Leadership Position
B. Consultant/Advisory Role
C. Stock Ownership
D. Honoraria
E. Research Funding
F. Expert Testimony
G. Other Compensation

As corresponding author, I attest that the information on this form is true:

Name (please type or print)

Signature Date:

(Please use additional copies of this form for coauthors, if necessary. Mail to: Editor, JFAS, 2314 Waverly Street, Philadelphia, PA 19146; or fax (eFax) to 215-405-3974; or email scanned forms to: . Return only this final page. Do not return the preceding explanatory page. Thank you.)