JRGOS Mandatory Financial Disclosure Statement(required for each author/investigtor)
Investigator Name: Click here to enter text.
Please read the following statements and place a check in the box opposite the statement(s) that apply to you. If you have any financial interest or relationship to disclose, please check the box and include the name of the company or supplier. Your disclosure will be listed in the Final Program.
JRGOS does not view the existence of these interests or commitments as necessarilyimplying bias
or decreasing the value of your participation in its activities.
I (or a member of my immediate family) do not have a financial interest or other relationship with a commercial company or institution.
Please check all that apply below and list company name(s):
If you or members of your family, to the best of your knowledge, have any of the following financial interests or other relationships to any pharmaceutical; biomaterial; orthopaedic product, device, equipmentcompanyorsupplier:
1. Receive royalties for any product or device?
Click here to enter text.
2. Have served on the speaker’s bureau or have been paid an honorarium to present for any such company/supplier within
the last 12 months?
3. Are a paid/unpaid consultant or employee for any such company or supplier?
a. Employee Click here to enter text.
b. Paid Consultant Click here to enter text.
c. Unpaid Consultant Click here to enter text.
4. Own stock or stock options in any such company/supplier (excluding mutual funds)? Click here to enter text.
5. Direct Research or Institutional Support? Click here to enter text.
6. Other financial or material support? Click here to enter text.
Support from medical and/or orthopaedic publishers:
7. Royalties, financial or material support? Click here to enter text.
8. Serve on the editorial or governing board of any medical and/or orthopaedic publication? Click here to enter text.
9. Serve on any Board of Directors, as an owner, or Officer on a relevant committee of any health care organization
(e.g., hospital, surgery center, medical and/or orthopaedic professional society)?
Click here to enter text.
Signature: Date: Click here to enter a date.
To Insert Additional Disclosure Forms for other Authors/Investigators:
- Insert new page from the Word (2007 or later) toolbar: “Page Layout”, “Breaks”, “Page”.
- From the Word (2007 or later) toolbar, then “Insert”, “Quick Parts” (found on text sub-menu) and double click on the portion of Disclosure Form displayed. Form will automatically display on newly created page.
NOTE: If using an earlier version of Word, use this link to insert another copy of the form: copy and paste on top of next page to create a new page.