Peer Review Referee Disclosure Form 1

Disclosure Statement on Background Information for Applicants

for the Peer Review Process of “Integrated Healthcare Practitioners”

The information provided in this form has been collected by the editor-in-chief of “Integrated Healthcare
Practitioners” for the sole purpose of reviewing the eligibility of the individual identified herein to undertake an
impartial and unbiased review of a submitted manuscripted as part of the journal's peer-reviewed process. The
details provided herein by the individual will be kept in confidence which includes her or his identity not being
revealed to the author(s) in keeping with a single-blind framework. A “Conflict of Interest Disclosure” form will
be provided with each manuscript sent to a potential referee to help further clarify submission-specific
suitability.

It will be essential for any referee to keep the editor-in-chief of “IHP” abreast of any changes to the details
provided herein, thereby helping to ensure fairness both to the author(s) and her- or himself. Should not enough
space have been provided with this form, a separate signed and dated letter can be included with the additional
details under the subject heading: “Peer Review Referee Disclosure Supplementary Information.”

Name: _____________________________ Medical/Scientific Designation: _________________________

Address: _______________________________________ ___________________ ____ ____________
(street address) (city) (prov) (postal code)
Telephone Number: ( ____ ) ____ - __________ Fax Number: ( ____ ) ____ - __________
E-mail: _______________________________

Current Employer: ________________________________ Position: _______________________________

Address: _______________________________________ ___________________ ____ ____________
(street address) (city) (prov) (postal code)
Telephone Number: ( ____ ) ____ - __________

Highest Level of Education Obtained: _________________________________________________________

From which Institution: ______________________________________________ Completed: ____/______

(mm/yyyy)
Peer Review Activities with “IHP”:

What are your current area(s) of specialization (please select from Medical Subject Headings offered by the
National Library of Medicine http://www.nlm.nih.gov/mesh/)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

During which period would you like to receive manuscripts to review: from: ____/______ to: ____/______
(mm/yyyy) (mm/yyyy)

How many manuscripts are you comfortable reviewing during a single period: _________
 Peer Review Referee Disclosure Form 2

Previous Peer-Reviewing Experience:

(a) Journal: ________________________________________ From: _________ To: _________

Subject Area of Manuscript Number of Manuscripts Reviewed in this Subject Area

________________________ _______
________________________ _______
________________________ _______

(b) Journal: ________________________________________ From: _________ To: _________

Subject Area of Manuscript Number of Manuscripts Reviewed in this Subject Area

________________________ _______
________________________ _______
________________________ _______

(c) Journal: ________________________________________ From: _________ To: _________

Subject Area of Manuscript Number of Manuscripts Reviewed in this Subject Area

________________________ _______
________________________ _______
________________________ _______
________________________ _______
 Peer Review Referee Disclosure Form 3

Professional Activities:

Published Articles:

1. Article Title: ________________________________________________________________________

________________________________________________________________________
Co-Author(s): ________________________________________________________________________
________________________________________________________________________
Journal Title: _________________________________ Year: _____ Vol: ____ Pagination: ________

Peer-Reviewed: yes □

2. Article Title: ________________________________________________________________________

________________________________________________________________________
Co-Author(s): ________________________________________________________________________
________________________________________________________________________
Journal Title: _________________________________ Year: _____ Vol: ____ Pagination: ________

Peer-Reviewed: yes □

3. Article Title: ________________________________________________________________________

________________________________________________________________________
Co-Author(s): ________________________________________________________________________
________________________________________________________________________
Journal Title: _________________________________ Year: _____ Vol: ____ Pagination: ________

Peer-Reviewed: yes □

4. Article Title: ________________________________________________________________________

________________________________________________________________________
Co-Author(s): ________________________________________________________________________
________________________________________________________________________
Journal Title: _________________________________ Year: _____ Vol: ____ Pagination: ________

Peer-Reviewed: yes □

Other (i.e., conference addresses, presentations): (please indicate conference name; date; location; and any
academic, institutional or corporate affiliation)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
 Peer Review Referee Disclosure Form 4

Research Activities: (excluding present employer)

(a) Activity/Project: ________________________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________
Sponsor: ___________________________________
Type of Support (i.e., funding, equipment, facilities): _____________________________________________
__________________________________________________________________________________________
Project Status: □ ongoing □ completed □ other (i.e., pending review): ______________________________

(b) Activity/Project: ________________________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________
Sponsor: ___________________________________
Type of Support: ___________________________________________________________________________
__________________________________________________________________________________________
Project Status: □ ongoing □ completed □ other: ______________________________

(c) Activity/Project: ________________________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________
Sponsor: ___________________________________
Type of Support: ___________________________________________________________________________
__________________________________________________________________________________________
Project Status: □ ongoing □ completed □ other: ______________________________

(d) Activity/Project: ________________________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________
Sponsor: ___________________________________
Type of Support: ___________________________________________________________________________
__________________________________________________________________________________________
Project Status: □ ongoing □ completed □ other: ______________________________
 Peer Review Referee Disclosure Form 5

Institutional Affiliations: (“Relevant Relationship” includes investments and/or position held, for instance,
Board of Directors, Advisory Board member and so on)

(a) _____________________________________________________________________________________
Address: _______________________________________ ___________________ ____ ____________
(street address) (city) (prov) (postal code)
Form of Remuneration (if any): _______________________ Volunteer Basis: □ yes □ no
Relevant Relationship (if any): _______________________________________________________

(b) _____________________________________________________________________________________
Address: _______________________________________ ___________________ ____ ____________
(street address) (city) (prov) (postal code)
Form of Remuneration (if any): _______________________ Volunteer Basis: □ yes □ no
Relevant Relationship (if any): _______________________________________________________

(c) _____________________________________________________________________________________
Address: _______________________________________ ___________________ ____ ____________
(street address) (city) (prov) (postal code)
Form of Remuneration (if any): _______________________ Volunteer Basis: □ yes □ no

Corporate Affiliations: (i.e., for “Position” research consultant)

(a) ____________________________________________________ Position: __________________________

Address: _______________________________________ ___________________ ____ ____________
(street address) (city) (prov) (postal code)
Form of Remuneration (if any): _______________________ Volunteer Basis: □ yes □ no
Relevant Relationship (if any): _______________________________________________________

(b) ____________________________________________________ Position: __________________________

Address: _______________________________________ ___________________ ____ ____________
(street address) (city) (prov) (postal code)
Form of Remuneration (if any): _______________________ Volunteer Basis: □ yes □ no

(c) ____________________________________________________ Position: __________________________

Address: _______________________________________ ___________________ ____ ____________
(street address) (city) (prov) (postal code)
Form of Remuneration (if any): _______________________ Volunteer Basis: □ yes □ no
 Peer Review Referee Disclosure Form 6

_______________________________________ ____________________________
(Signature) (Date)