Peer Review Conflict of Interest Disclosure Statement 1

Conflict of Interest Disclosure Statement for Peer Reviewers for a Given

Manuscript

The information contained within this document is being solicited from the peer reviewer to “IHP” by the latter
in confidence in conjunction with helping to make a determination that no confict of interest exists with the
person identified herein which would preclude her/him from evaluating the specified submitted manuscript.
While the peer-review process is a single-blind one and, thus, in reviewing this document the potential reviewer
will have been given knowledge of aspects of the submitted manuscript, in expressing interest in the specified
manuscript prior to receiving this document, s/he has reaffirmed that the confidence of the authors will be
respected by her/him and that no details identified herein with respect to the manuscript will be divulged in any
manner to any person and that correspondence concerning the manuscript will be addressed solely to the Editor-
in-Chief of “IHP.”

Appended is a sheet upon which the potential reviewer is asked to identify any relationship which has existed or
currently exists as well as the nature, dates and duration of that relationship with any of the authors, institutions,
corporations and funding bodies identified within this document which s/he or those of her or his immediate
family (spouse and children) has or has had. These relationships may include, for instance:

1. having worked with a cited author on another manuscript/published article or a study which was
terminated;
2. currently working with a cited author on a study which is either ongoing or has been suspended
temporarily;
3. currently working on a manuscript with or in association with (i.e., in an advisory role) a cited author
which is to be submitted for publication;
4. a directorship with, any form of remuneration from, or investments in any company or institution which
has been associated with the submitted manuscript to “IHP” which may involve the submitted
manuscripts's funding sources, materials, equipment, and/or the site(s) of the study itself , or in the case
of a review article the products/matierals described therein.

In addition, the peer reviewer is asked to provide the bibliographic information of co-authored published articles
or articles in which s/he or any immediate family member was involved (as described above).

Manuscript Number: ___________________________ Date Sent to Peer Reviewer: ___ / ___ / ____
dd / mm / yyyy

Name of Peer Reviewer: ___________________________________________

Authors: (1) _______________________________________________________

(2) _______________________________________________________

(3) _______________________________________________________

(4) _______________________________________________________

(5) _______________________________________________________
 Peer Review Conflict of Interest Disclosure Statement 2

Manuscript Number: ____________________ Peer Reviewer's Name: _____________________________

Sponsorship of the Study:

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Site(s) at which the Study was Conducted:

(1) _______________________________________________________________________________________

(2) _______________________________________________________________________________________

(3) _______________________________________________________________________________________

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(Peer Reviewer's signature) (Date)
 Peer Review Conflict of Interest Disclosure Statement 3

Manuscript Number: ____________________ Peer Reviewer's Name: _____________________________

Details of Relationships as Outlined above:

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(Peer Reviewer's signature) (Date)