Conflict of Interest Disclosure Form

Disclosure of financial relationships with commercial interests: (The ACCME defines a "commercial interest" as any entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests. For more information, visit www.accme.org.)

First Name *

Last Name *

Credentials *

DO

MD

Other...

Credentials Other...

E-mail *

Date *

Month

Day

Year

Please select the journal for which you are completing a manuscript review: *

Clinical Imaging

Please select the statement that best describes you: *

I declare that I or my spouse/partner do not/does not have a financial relationship with any commercial interest.

I declare that I or my spouse/partner do/does have a financial relationship with any commercial interest within the last 12 months. (Please specify below.)

Commercial Interest *

Disclosures should include relationships in any amount.

	Myself	Partner	N/A
Speakers Bureau	Speakers Bureau - Myself	Speakers Bureau - Partner	Speakers Bureau - N/A
Consultant, advisor	Consultant, advisor - Myself	Consultant, advisor - Partner	Consultant, advisor - N/A
Stock Ownership	Stock Ownership - Myself	Stock Ownership - Partner	Stock Ownership - N/A
Research Grant	Research Grant - Myself	Research Grant - Partner	Research Grant - N/A
Employment Affiliation	Employment Affiliation - Myself	Employment Affiliation - Partner	Employment Affiliation - N/A
Royalties, patents	Royalties, patents - Myself	Royalties, patents - Partner	Royalties, patents - N/A

Name of Commercial Interest Entity (*n/a if none) *

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Conflict of Interest Disclosure Form