№ lp_2_1_13217
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Character count: 3313
File size: 37 KB
Standardized form used for authors to declare financial and other relationships that could represent a conflict of interest related to their submitted manuscript, including grants, royalties, consulting, and other financial or non-financial interests.
Date:
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Author:
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Manuscript Title:
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US-based Author:
YES/NO
Manuscript Number:
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Journal:
Ophthalmology
Reference:
Van Gelder RN and Siegfried CJ, Ophthalmology, 2022; 129: 602-604
Disclosure Type:
Conflict of Interest
Time Frame:
Item #1 – since initial planning of the work; other items – past 36 months
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Note:
Year
Date:
3/19/2025
Your Name:
Daniela Seidel
Manuscript Title:
JBJS Associate Editor
Manuscript Number:
NA
Type of Document:
Disclosure Form
Purpose:
Declaration of relationships, activities, and interests
Time Frame:
Since initial planning of the work and past 36 months
Status:
All items marked as None
Note:
Year
Date:
7/13/2023
Author:
Ronald W. Lindsey, MD
Manuscript Title:
JBJS Deputy Editor
Manuscript Number:
Not provided
Document Type:
Conflict of Interest Disclosure Form
Organization:
International Committee of Medical Journal Editors (ICMJE)
Subject:
Disclosure of relationships/activities/interests related to manuscript content
Time Frame Item 1:
Since the initial planning of the work
Time Frame Items 2–13:
Past 36 months
Editorial Roles Disclosed:
Co-Editor, Texas Orthopaedic Journal; Co-Editor, Journal of Bone and Joint Surgery (JBJS) Case Connector
Patents Issued:
Tissue Integration Design for Seamless Implant Fixation; Mesh Bone Screw
Patents Pending:
Treatment of Subjects Undergoing Orthopaedic Surgery and Local Radiation Using Thrombin Derived Peptides
Advisory Role:
Member of the Advisory Board for the Max Biedermann Institute for Biomechanics at the University of Miami and the Mount Sinai Medical Center in Miami Beach, Florida
Certification Statement:
Author certified completion and accuracy of all responses
Note:
Year
Document Type:
Author Disclosure Form
Issuing Organization:
International Committee of Medical Journal Editors (ICMJE)
Purpose:
Disclosure of Relationships and Conflicts of Interest
Related Journal:
Maltepe Tıp Dergisi
Scope:
Financial and Non-Financial Interests Related to Manuscript Submission
Time Frame:
Since Initial Planning of the Work and Past 36 Months
Sections Included:
Financial Support, Grants, Royalties, Consulting Fees, Honoraria, Expert Testimony, Travel Support, Patents, Advisory Roles, Stock Ownership, Other Interests
Additional Declarations:
Patient Consent, Ethics Committee Approval
Certification Requirement:
Author Confirmation of Complete and Unaltered Responses
Signatories:
Contributing Authors and Corresponding Author
Date:
6/26/23
Your Name:
Kimberly Templeton, MD
Note:
Manuscript Title
Year:
2023
Region / city:
Kansas
Subject:
Manuscript disclosure
Document type:
Disclosure form
Organization / institution:
University of Kansas Medical Center
Author:
Kimberly Templeton, MD
Target audience:
Authors of academic manuscripts
Period of validity:
Not specified
Approval date:
Not specified
Date of changes:
Not specified
Note:
Year
Note:
Year
Document Type:
Deed
Year:
Not applicable
Region / City:
Not applicable
Subject:
Research ethics and manuscript submission
Document Type:
Submission Template
Organization / Institution:
Not applicable
Author:
Not applicable
Target Audience:
Researchers, Authors submitting manuscripts
Period of validity:
Not applicable
Approval Date:
Not applicable
Date of Changes:
Not applicable
Year:
2022
Region / City:
Addis Ababa, Ethiopia
Topic:
Environmental and Social Management Framework
Document Type:
Report
Author:
Ministry of Finance
Target Audience:
Government bodies, development organizations, stakeholders involved in project implementation
Period of Effectiveness:
Not specified
Approval Date:
August 2022
Amendment Date:
Not specified
Description:
This document is a framework for managing environmental and social impacts of the 3R-4-CACE project in conflict-affected communities in Ethiopia, outlining policy, legal frameworks, risks, and mitigation measures.
Year:
2020
Region / City:
Ukraine, Kyiv
Topic:
Nature-based solutions, urban development, climate change adaptation
Document Type:
Project report
Organization:
UNDP Ukraine
Author:
UNDP Ukraine
Target Audience:
Local authorities, national policymakers, NGOs, community groups, environmental stakeholders
Period of Implementation:
2019-2022
Approval Date:
November 2019
Amendment Date:
Not specified
Year:
2026
Region / City:
Oregon
Subject:
Conflict of Interest Disclosure
Document Type:
Form
Institution:
Oregon Department of Transportation
Author:
Oregon Department of Transportation
Target Audience:
Firms under contract with the Agency
Period of Validity:
Not specified
Approval Date:
Not specified
Modification Date:
Not specified
Year:
2019
Region / City:
Global
Topic:
Health Emergencies, Armed Conflict, Medical Response
Document Type:
Guidance Document
Organization / Institution:
WHO, ICRC, MSF, DG ECHO, US OFDA, UN agencies
Author:
WHO EMT Secretariat, Peer Review and Drafting Group
Target Audience:
Medical teams, humanitarian organizations, military units, governmental agencies
Effective Period:
Ongoing
Approval Date:
Pending
Date of Last Revision:
Sept 9, 2019
Year:
2023
Region / City:
N/A
Topic:
Conflict of Interest Disclosure
Document Type:
Form
Organization / Institution:
Bentham Open
Author:
N/A
Target Audience:
Authors submitting manuscripts to Bentham Open
Effective Period:
N/A
Approval Date:
N/A
Date of Changes:
N/A
Year:
2013
Region / City:
Chittagong
Topic:
Conflict Management, Workplace Issues
Document Type:
Assignment
Institution:
University of Science & Technology Chittagong
Author:
B.K. Dhar
Target Audience:
Students, Academics, Professionals in Business Administration
Period of Validity:
N/A
Approval Date:
August, 2013
Modification Date:
N/A
Year:
2017
Region / City:
International
Topic:
Sexual Violence in Conflict, Training Materials
Document Type:
Training Materials
Organization / Institution:
Institute for International Criminal Investigations (IICI)
Author:
Institute for International Criminal Investigations (IICI)
Target Audience:
Trainers, International Law Practitioners
Period of Validity:
Ongoing
Approval Date:
March 2017
Date of Changes:
N/A
Year:
Not specified
Region / City:
Haidian District, Beijing City
Theme:
Social Identity, Planning Horizons, Social Identity Conflict
Document Type:
Research Supplement
Organization / Institution:
Not specified
Author:
Not specified
Target Audience:
Researchers, Academics
Period of Validity:
Not specified
Approval Date:
Not specified
Modification Date:
Not specified
Year:
[insert year]
Region / city:
[insert name of church]
Subject:
Conflict of Interest, Governance
Document Type:
Policy
Organ / institution:
[insert name of church]
Author:
Elders/Board
Target audience:
Paid staff, leadership, ministry and volunteer roles at [insert name of church]
Period of validity:
Ongoing
Approval Date:
[insert date]
Amendment History:
[insert date and reason for amendment]
Note:
Year
Topic:
Conflict of Interest, Commitment Management
Document Type:
Management Plan
Organization:
University of Illinois
Author:
Professor XYZ
Target Audience:
University Faculty and Administration
Period of Validity:
Annual