Proceedings of UCLA Healthcare Author S Form (Rev. 7/16)

Proceedings of UCLA Healthcare Author’s Form (rev. 7/16)

Please note & initial: A manuscript may be returned if any of the requirements listed in the Information for Authors section is not met (see Proceedings of UCLA Healthcare website http://proceedings.med.ucla.edu, under “FOR AUTHORS”). PLEASE INITIAL HERE THAT ONE OR MORE AUTHORS HAS READ THE INFORMATION FOR AUTHORS:

Manuscript Working Title:

Manuscript Keywords (please include to be used as a searchable feature on Proceedings website):

Article Format (check one): ___ Clinical Vignette ___ Clinical Commentary ___ Original Research

___ Brief Clinical Update ___ Clinical Review

Authorship and Dual Commitment:

- My signature below verifies that this paper represents my original work and that the contents, whether verbatim or rephrased, have not been previously published or submitted elsewhere. All listed authors must complete this form.

- My signature below verifies that I have disclosed any financial interest (i.e.outside support) or other dual commitments that may represent a potential conflict of interest (i.e. shareholder in a company, participation on a speakers’ bureau, etc.) to the Editor in a cover letter.

Print Name Signature Date

Print Name Signature Date

Copyright Transfer:

Authors must transfer copyright, to the Department of Medicine at UCLA, publisher of the Proceedings. Transfer of copyright signifies transfer of right for print, electronic or mechanical publication in a language other than English. Permission is usually granted on request and without charge for authors to use portions of their works published in the Proceedings for educational purposes and in other scholarly publications.

Print Name Signature Date

Print Name Signature Date

EVERY AUTHOR must complete/sign this page (separate copies may be submitted).

FOR MULTI-AUTHORED papers (3 authors or more), each author should ALSO complete the following page.

** Completed/signed forms should be returned to Betty Morgan by email attachment or by fax at 310-206-3489. **

Proceedings of UCLA Healthcare Authors’ Form

MULTI-AUTHORED MANUSCRIPT

(Complete ONLY if there are 3 or more authors)

Manuscript Working Title:

Author

Specific Role in Manuscript Preparation

Author

Specific Role in Manuscript Preparation

Author

Specific Role in Manuscript Preparation

Author

Specific Role in Manuscript Preparation