CONFLICT OF INTEREST FORM

                                                                       PANACEA

ISSN (P): --------, (E): ------

 

  

 PANACEA Journal: Conflict of Interest Disclosure Form

Manuscript Information: ________________________________________

Title of Manuscript: ____________________________________________

 

Type of Article:

☐ Original Article                     ☐ Review Article                             ☐ Case Report

☐ Short Communication          ☐ Letter to Editor                            ☐ Editorial

☐ Other: ______________________

 

Author Information

Full Name of Author: ___________________________________________

Institution / Affiliation: _________________________________________

Department: ____________________________________________________

Email Address: __________________________________________________

ORCID ID (if available): __________________________________________

Conflict of Interest Disclosure

A conflict of interest exists when professional judgment concerning a primary interest (such as scientific integrity or patient welfare) may be influenced by a secondary interest including financial gain, personal relationships, academic competition, or institutional affiliations.

Authors are required to disclose all potential conflicts of interest related to the submitted work.

Section A — Financial Conflicts of Interest

Please indicate whether you or your institution have received any of the following related to this manuscript:

Type of Financial Relationship Yes No

Research grants or funding ☐ ☐

Consultancy fees ☐ ☐

Honoraria or speaker fees ☐ ☐

Employment or advisory role ☐ ☐

Stock ownership or shares ☐ ☐

Patents or intellectual property interests ☐ ☐

Travel grants or sponsorship ☐ ☐

Equipment, drugs, or materials support ☐ ☐

Any other financial relationship ☐ ☐

If “Yes,” please provide details: ______________________________________________

________________________________________

Section B — Non-Financial Conflicts of Interest

Please disclose any non-financial conflicts that may influence the work, including:

• Personal relationships

• Academic competition

• Institutional affiliations

• Political or religious considerations

• Professional rivalries

• Personal beliefs relevant to the study

☐ No non-financial conflict exists

☐ Yes (please specify): _________________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

Section C — Funding Disclosure

Please provide details of all funding sources supporting this work:

☐ No external funding received

☐ Funding received from: ___________________________________________________

Grant Number (if applicable): _______________________________________________

Author Declaration

I hereby declare that:

1. The information provided in this form is accurate and complete to the best of my knowledge.

2. All potential conflicts of interest relevant to this manuscript have been disclosed.

3. I understand that failure to disclose conflicts of interest may result in rejection, correction, or retraction of the published article.

4. I agree to comply with the ethical and publication policies of PANACEA Journal.

Signature of Author: ______________________________

Name: __________________________________________

Date: ________________

For Editorial Office Use Only

Date Received: _______________________

Reviewed By: ________________________

Editorial Decision: ___________________

 

☐ No Conflict Identified

☐ Conflict Declared and Managed

☐ Further Clarification Required

Remarks: ______________________________________________________________________

_______________________________________________________________________________

 

Publication Ethics and Transparency Policy

The journal follows the ethical standards and recommendations of the Committee on Publication Ethics and the International Committee of Medical Journal Editors (ICMJE).