Manuscript Title:      	

Journal:      	

All authors:      	
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The Expert Collection does not discriminate on the basis of the source of material submitted to its journals, provided full disclosure is provided and appropriate declaration of interest statements and acknowledgments are included in published manuscripts.  
 
We ask the Corresponding Author (or another principal Coauthor) to complete this form on the part of all authors, taking into consideration all relevant disclosure for each author. 

Some or all of the information below may be published at the discretion of the Editor as a Declaration of Interest statement in the Acknowledgment section of the manuscript. Please note that this section must be present before we initiate peer review.  

1. The manuscript submitted represents original work and has not been previously published or simultaneously submitted elsewhere for publication.
Yes to all above     
No, because      	

2. The manuscript has been read and approved by all authors. 
Yes     
No, because      	

3. All conditions as stated by the International Committee of Medical Journal Editors (ICMJE; Hhttp://www.icmje.orgH) have been met. 
Yes     
No, because      	

4. For clinical studies, the body providing explicit ethical approval of the work reported has been stated in the manuscript.
Yes     
No, because      	

5. For clinical trials, please provide trial registration information and a trial registration number for the study (where available):
     	
6. How has your paper been sponsored/funded? Please name all academic bodies, and/or pharmaceutical (or other) companies that have supported this work, in whole or in part.
     	
Authorship/disclosure/‘contributorship’
7.1 If any employees of the sponsors/other contributors meet the criteria for authorship (as per ICMJE guidelines – see first bullet point under section IIA. 1 of the Uniform Requirements – Hhttp://www.icmje.org/H), then, these individuals should be added as authors on the manuscript. 
7.2 If they do not meet authorship criteria, but the sponsor/other contributor(s) had a role in the preparation of the manuscript, this should be explained. Did the sponsors have a role in article preparation – study design/data analysis/statistical input/review of drafts/writing of the article/identification of papers for inclusion/any other form of input? 
Describe here:      	

8. A statement of financial, commercial or other relationships of a declarable nature relevant to the manuscript being submitted, (i.e., associations/relationships with the sponsors or any other associations which might lead to a potential conflict of interest), must be provided. 

Please include the following information for each individual coauthor: 
•	Disclosure of sources of support in the form of sponsorship, grants, materials, etc.   
•	Declaration of interest, including grants, fellowships, or commercial assistance or financial sponsorship received; or of any affiliation, organization or entity which is relevant.  
 
Lead author: Name:      	
Disclosure:      	

Corresponding author: Name:      	
Disclosure:      	

Coauthor: Name:      	 
Disclosure:      	

Coauthor: Name:      	
Disclosure:      	

 (Use additional pages if this space is insufficient.) 
 
9.1 Acknowledge any further contributions to this paper, such as data analysis, statistical analysis, data collection, data management or any other assistance. 
9.2 We recognise the role of the professional medical writer and medical communication agencies. In case any writing/editorial assistance was taken for the preparation of this article, then, include also the agency and the writer(s)/person(s) to be acknowledged.  

Name and affiliation:      	
Nature of contribution:      	

Name and affiliation:      	
Nature of contribution:      	
(Use additional pages if this space is insufficient.) 
 
I confirm that I, all coauthors, medical writers and other contributors to the manuscript have provided full disclosure regarding any relevant relationships, financial and otherwise.  

	     
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          Corresponding author signature                                                               Date    

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