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Manuscript number:__________________ Author’s name (please print):_______________________________

Manuscript title: ______________________________________________________________________________

Each author should complete and return this form to the corresponding author.
Disclosures should be entered online at the time of submission. The corresponding author is encouraged to keep completed forms on file for future reference.
All authors submitting work to the Clinical and Experimental Otorhinolaryngology are required to disclose any real or apparent relationships with industry that may have a direct bearing on relevant subject matter.
For all disclosures, fill in all sections and sign the last page (attach additional sheets as needed).

Check yes if you or a family member is employed by any entity having an investment, licensing, or other commercial interest in any drugs, products, or services that are the subject of the matter under consideration. YES   NO
Check yes if you or a family member serves as an officer or board director of any entity having an investment, licensing, or other commercial interest in any drugs, products, or services that are the subject of the matter under consideration. YES   NO
Check yes if you or a family member has served as a consultant or advisor within the last 2 years to an entity having an investment, licensing, or other commercial interest in any drugs, goods, or services that are the subject of the matter under consideration. YES   NO
Check yes if you or a family member have any ownership interest in a start-up company, the stock of which is not publicly traded, or in any publicly traded company (except when invested in a diversified fund not controlled by you or an immediate family member) in an entity having an investment, licensing, or other commercial interest in any drugs, goods, or services that are the subject of the matter under consideration. YES   NO
Check yes if honoraria have been paid directly to you or a family member within the last 2 years by an entity having an investment, licensing, or other commercial interest in any drugs, goods, or services that are the subject of the matter under consideration. YES   NO
Check yes if you, a family member or your institution have received payment in connection with the conduct of the clinical research projects in question provided by the trial sponsor or agents employed by the sponsor. YES   NO

I confirm that the information reported is accurate. I understand that, where appropriate, this information may be disclosed publicly. I further understand that the Korea Society of Otorhinolaryngology-Head and Neck Surgery reserves the right to decline to publish my work if the Society believes a significant conflict of interest exists. Furthermore, I understand that failure to complete this disclosure declaration will disqualify me from submitting my manuscript to the Clinical and Experimental Otorhinolaryngology.

Corresponding Author

Signature: _________________________________      Date: _________________________________

Print name: _________________________________________________________________________

Co-Authors

Signature: _________________________________      Date: _________________________________

Print name: _________________________________________________________________________

Signature: _________________________________      Date: _________________________________

Print name: _________________________________________________________________________

Signature: _________________________________      Date: _________________________________

Print name: _________________________________________________________________________

Signature: _________________________________      Date: _________________________________

Print name: _________________________________________________________________________

Signature: _________________________________      Date: _________________________________

Print name: _________________________________________________________________________

Signature: _________________________________      Date: _________________________________

Print name: _________________________________________________________________________

Signature: _________________________________      Date: _________________________________

Print name: _________________________________________________________________________

Editorial Office
Korean Society of Otorhinolaryngology-Head and Neck Surgery
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