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Each author must read and sign the statements on:
as well as the separate form for (A) Copyright Transfer or Federal Employment.
In addition, the corresponding author must complete and sign the:
This form is available online at http://mc.manuscriptcentral.com/societyimages/hsr/Author%20Responsibility%20Form-Draft-8-29.doc. If necessary, it may be photocopied and distributed to coauthors or other contributors.
Note: We require hard copies of (1) the certifications and (A) copyright transfer forms before publication. We need electronic versions of (2 and 3) the individual disclosures, (4) collective acknowledgment/disclosure statement, and (5) contributorship matrix. The latter two will be published electronically and the acknowledgment/disclosure statement will also appear in the print version. The individual disclosure statements will be reviewed by the editors to make sure that all necessary and relevant information that readers need to know to evaluate the work published in HSR has been reflected in the acknowledgment/disclosure paragraph; detailed disclosures will not be published.
It is the responsibility of the corresponding author to obtain the information necessary to prepare the contributorship and acknowledgment/disclosure statements and to obtain the signatures and disclosures of each author and mail these to the Managing Editor. The corresponding author should collect the disclosure information from each co-author and then prepare a draft joint acknowledgment/disclosure statement along with the matrix. This joint statement should be reviewed by each author.
The wording of the acknowledgment/disclosure statement and contributorship matrix may undergo some negotiation with the editors, either to eliminate some material that is not needed or to include some that should be disclosed. To speed the process, authors may submit drafts of their disclosures, and the corresponding author may submit a draft of the joint statement. These can be submitted electronically at any time during our processing of the manuscript and will be reviewed for consistency and completeness when the manuscript is close to acceptance. If submitting information as draft, please fill out the form electronically (signatures are not needed at this point) and submit it via Manuscript Central as a PDF document labeled in the format MS XX-YYY-DISCLOSURE-lastname_of_each_author (e.g., MS 06-347-DISCLOSURE-Smith or MS 06-347-DISCLOSURE-Jones). The final language of both the acknowledgment/disclosure statement and contributorship matrix must be included with the signed hardcopy certification and copyright transfer forms before we will forward the manuscript to Blackwell for copyediting.
Health Services Research
Certification and Disclosures by Authors
Manuscript Number: MS-
[After submitting your manuscript online, your manuscript is assigned a number that must be entered in the space above].
Only the corresponding author needs to fill in the following table:
INSTRUCTIONS: EACH AUTHOR MUST FILL OUT AND SIGN SECTIONS 1–3:
(Hardcopy with signature is only necessary with the final version of the manuscript)
1. Authorship Responsibility, Criteria, and Contributions. Each author should meet all criteria below (A, B, C, and D) and should indicate his or her general and specific contributions by checking the appropriate boxes. Research and manuscripts may depend critically on various individuals who do not meet all the criteria for authorship; they should be acknowledged as contributors in section 4 below. Note: the corresponding author should include below (in section 5) a separate document summarizing the public acknowledgments/disclosures to appear in the printed version of your manuscript, This summary statement should be consistent with and reflect all significant disclosures of each of the individual authors.
□A. I certify that
□B. I have given final approval of the submitted manuscript and each of its revisions, if any.
□C. I have participated sufficiently in the work to take public responsibility for (check 1 or 2 below)
□1. the whole content.
□2. part of the content: (fill in as appropriate)
□D. To qualify for authorship, you must check at least 1 box for each of the 2 categories of contributions listed below. For examples of contributions that qualify for acknowledgment but not for authorship, see section 4 below.
I have made substantial contributions to the intellectual content of the paper as described below.
1. (check at least 1 of the 3 below)
□a. conception and design
□b. acquisition of data
□c. analysis and interpretation of data
2. (check at least 1 of 2 below)
□a. drafting of the manuscript
□b. critical revision of the manuscript for important intellectual content
Your SignatureDate Signed
2. Financial Disclosure.. For the purposes of this disclosure and the one below, “conflicts of interest” include not only situations in which decisions and judgment have been influenced, but also those that may, if subsequently disclosed or uncovered, lead readers to question whether decisions or judgment may have been influenced by such situations. We anticipate that the vast majority of “conflicts,” if disclosed in advance, will have little bearing on a reader's assessment of the research, and no bearing on our decision to publish. Except in cases in which all the authors certify they have nothing to disclose, the corresponding author will submit (both electronically and in hard copy) a brief acknowledgment/disclosure of the conflicts of all the authors. Please check the appropriate boxes below (applies to the past five years and foreseeable future):
□a. I have no relevant financial interests pertaining to this manuscript.
□b. I certify that all my conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (e.g., employment / affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are disclosed below:
□c. I certify that all financial and material support (including those providing data or access to patients, interviewees, etc.) for this research and work are clearly identified in an acknowledgment/disclosure section to be published with the manuscript.
□d. I certify that I agree with the description in the Acknowledgments/Disclosures statement in Section 5 of any support for the project or conflicts of interest as they pertain to myself.
Your SignatureDate Signed
3. Other Disclosures. Aside from financial interests, there may be other real or potential conflicts that need to be disclosed. In particular, we are concerned about situations in which an external sponsor, provider of data, or other entity may be able to influence either an author's ability to publish or to shape what he or she seeks to publish. We are also concerned that an author, or organizations with which he or she is affiliated may have taken certain positions relevant to the research that should be disclosed. We may require that such information be publicly acknowledged. For the purposes of this disclosure, the term “contractual right” includes not only formal contracts and memoranda of understanding with outside parties, but also the rights of your employer to review and or approve your publications. Please check the appropriate boxes below and provide the information requested:
a.Sponsors and/or supporters of this research, e.g., organizations providing data, or supervisors within my own organization have:
□i.a contractual right to review and approve the manuscript before submission or publication
□ii.a contractual right to review and comment on the manuscript within ___ days, after which it can be submitted without constraint
□iii.no contractual rights to review the manuscript before submission, but there is a requirement that the sponsor/supporter be given a copy of the accepted manuscript prior to publication
□iv.no requirement for prior approval or notification, but I solicited feedback and/or plan to provide an advance copy as a courtesy
□v.the manuscript has not been reviewed or commented upon by the sponsor(s) and I have no plans to provide advance notification
If you checked any of the boxes i through iv, please indicate the organizations involved and the circumstances. (For example, some organizations require that manuscripts undergo internal peer review for comment, but an author may publish any findings he or she wishes.)
A contractual right by a sponsor, supporter, or employer to review and approve (and hence censor) a manuscript makes it appear to be a “work for hire” rather than research. On occasion such work may warrant publication in HSR, e.g., because it illustrates novel methods, but we will be reluctant to accept a manuscript with findings or conclusions that might be influenced by the ability of the sponsor to withhold permission to publish.
□b.I have taken public stands (e.g., in print, media, expert witness, legislative testimony or other venues, with or without compensation) that are identified with a particular advocacy position relevant to the manuscript.
□c.The organization with which I am currently (or was, at the time of the manuscript's preparation) affiliated (as a spokesperson, board member, or similar prominent position) is identified with a particular advocacy position relevant to the manuscript.
If you checked boxes b or c disclosing what are likely to be significant issues, please work with the corresponding author to include in the acknowledgments/disclosures section a statement that will alert readers to such positions or where they can obtain more information. Our experience to date is that many authors “over-disclose” and we have no desire to either overexpose our authors or overburden our readers. The best approach is to disclose fully in the text boxes above (e.g., “my department chair requires that all manuscripts of junior faculty be reviewed and commented upon by senior faculty”) while focusing in the proposed public disclosure on issues likely to be of concern to readers (e.g., “I have been retained as an expert witness in a case related to this research.”) The editors will work with the corresponding author to resolve any questions as to how much detail needs to be in the final acknowledgment/disclosure statement.
□d.I certify I agree with the description in the Acknowledgments/Disclosures statement in Section 5 of disclosures as they pertain to myself.
Your SignatureDate Signed
INSTRUCTIONS: THE CORRESPONDING AUTHOR MUST FILL OUT AND SIGN SECTIONS 4 and 5:
□4. Contributorship matrix. Please complete and attach a matrix of the following form, filling in the contributions of each person involved in the research or preparation of the manuscript*:
Corresponding Author SignatureDate Signed
5. Joint Acknowledgment/Disclosure Statement. Please enter a 1–3 paragraph statement that acknowledges all forms of financial and material support for the project, the roles of key individuals who should be recognized; (this may or may not extend to everyone listed in the contributorship matrix.) Please also include summary statements about what you feel are the conflicts of interests and disclosures without which some readers may feel that important relevant information is being withheld. The editors will determine whether these disclosures are sufficient or excessive and return a revised version. All authors will need to approve the final version.
Joint Acknowledgment/Disclosure Statement:
The corresponding author should obtain and retain written permission from all individuals named in an Acknowledgment or the Contributorship Matrix, since readers may infer their endorsement of data and conclusions.
The corresponding author must sign below indicating his/her certification that:
Corresponding Author SignatureDate Signed
(Adapted, with permission, from the Journal of the American Medical Association, 2006)