Canadian Journal of Diabetes

182 |

caNaDIaN JOUrNaL OF DIaBETES

rEvISED March 2009

Duality of Interest Disclosure Form Canadian Journal of Diabetes

The Canadian Diabetes Association must ensure balance, independence, objectivity and scientific rigour in all its individually or jointly sponsored educational activities and publications. All participants in a sponsored activity are expected to disclose any significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider(s) of any commercial services. Significant financial interest or other relationship includes: employment (full- or part-time); membership on the board of directors or any fiduciary relationship; membership on a scientific Title of paper

advisory panel or other standing scientific/medical committee; all consultative or advisory arrangements for which monetary compensation is received; and grants/research support. The intent of this disclosure is not to prevent an author with a significant financial or other relationship from submitting a manuscript. The information will be published with the manuscript under the heading “Author Disclosures.” It remains for the audience to determine whether the author’s interests or relationships may influence the paper with regard to exposition or conclusion.

________________________________________________________________________________

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 . . . . . . . . . . . . . . . . . . . . . . . o . . . o . . . . . . . . . . . . . . . . . o . . . o . . . . . . . . . . . . . . . . o . . . o Membership on an advisory panel, standing committee or board of directors . . . . . . . . . . . . . . . . . . o . . . o . . . . . . . . . . . . . . . . . o . . . o . . . . . . . . . . . . . . . . o . . . o Stock shareholder . . . . . . . . . . . . . . . . . . . . o . . . o . . . . . . . . . . . . . . . . . o . . . o . . . . . . . . . . . . . . . . o . . . o Honoraria or consulting fees . . . . . . . . . . . . o . . . o . . . . . . . . . . . . . . . . . o . . . o . . . . . . . . . . . . . . . . o . . . o Grant/research support . . . . . . . . . . . . . . . . o . . . o . . . . . . . . . . . . . . . . . o . . . o . . . . . . . . . . . . . . . . o . . . o 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.