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The purpose of this form is to provide readers of your manuscript with information about your other interests that could influence how they receive and understand your work. Each author should submit a separate form and is responsible for the accuracy and completeness of the submitted information. It is made and based on the form of ICMJE that is translated by KAMJE.

This section asks for information about the work that you have submitted for publication. The time frame for this reporting is that of the work itself, from the initial conception and planning to the present. The requested information is about resources that you received, either directly or indirectly (via your institution), to enable you to complete the work. Checking "No" means that you did the work without receiving any financial support from any third party -- that is, the work was supported by funds from the institution to where you belong, and your institution must not receive any funds from the third party. If you or your institution received funds from a third party to support the work, such as a government granting agency, charitable foundation or commercial sponsor, check "Yes".

Type No Yourself Institute Name of Third party
Consultation fee
Support of Travel for conferences or other purpose
Participation compensation for the review (Data monitoring committee, statistical analysis, and the result Committee)
Fee for the Manuscript preparation or Manuscript review
Manuscript preparation assistance, medicines, equipment, or administrative support
1. Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect of the submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)?
  • 1) Yes (explain below):

  • 2) No
2. Are there any other relationships or activities that influence readers or give them the appearance of potentially influencing from your submitted work?
  • 1) Yes, the following relationships/conditions/circumstances are present (explain below):

  • 2) No

At the time of manuscript acceptance, journals will ask authors to confirm and, if necessary, update their disclosure statements. On occasion, journals may ask authors to disclose further information about reported relationships.

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Corresponding author(s):                                                                                                            (signature)


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