Duality of Interest Disclosure Form Canadian Journal of Diabetes by ddx15455

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Duality of Interest Disclosure Form
Canadian Journal of Diabetes
Revised November 2005

The Canadian Diabetes Association must ensure balance,                       advisory panel or other standing scientific/medical commit-
independence, objectivity and scientific rigour in all its indi-             tee; all consultative or advisory arrangements for which mon-
vidually or jointly sponsored educational activities and publi-              etary compensation is received; and grants/research support.
cations. All participants in a sponsored activity are expected                  The intent of this disclosure is not to prevent an author
to disclose any significant financial interest or other relation-            with a significant financial or other relationship from submit-
ship with the manufacturer(s) of any commercial product(s)                   ting a manuscript.The information will be published with the
and/or provider(s) of any commercial services. Significant                   manuscript under the heading “Author Disclosures.” It
financial interest or other relationship includes: employment                remains for the audience to determine whether the author’s
(full- or part-time); membership on the board of directors                   interests or relationships may influence the paper with regard
or any fiduciary relationship; membership on a scientific                    to exposition or conclusion.


Title of paper ______________________________________________________________________________

Name of corresponding author __________________________________________________________________

Each author must sign this form (photocopy if needed).

I indicate below whether I have had a relevant duality of interest
in the past 12 months with a company whose products are directly
related to the topic of my manuscript.

Check each area that applies.
                                               Yes             No              Yes            No             Yes             No
Employment. . . . . . . . . . . . . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏
Membership on an advisory
panel, standing committee
or board of directors . . . . . . . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏
Stock shareholder . . . . . . . . . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏
Honoraria or consulting fees. . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏
Grant/research support . . . . . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏ . . . . . . . ❏

Author                             ____________________                  ______________________                   ______________________

Signature                          ____________________                  ______________________                   ______________________

Date                               ____________________                  ______________________                   ______________________

For each item checked “yes,” please list your relevant association on a separate sheet of paper.
Include the nature of the activity that is a relevant duality; the type of financial arrangement, if any,
between you and the organization; and a description of the business or purpose of the organization.

This form must be returned with your submission. Make additional copies as needed for all authors.

								
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