App Form List of Industry-Independent Medical Experts
This is the form for submitting updated contact information for The List, as well as the application for new members. Please answer all the relevant questions, even if you are already on the list in a previous format: having your contact information in the new system will prevent us from contacting you unnecessarily.
Academic title (professor, clinical adjunct, etc.)
If you would like to list your organizational affiliation(s), please fill in the name of the organization in the box. If you don't want to list them, just leave it blank.
Other (if other go to next question)
Country if "Other"
City or Province:
Availability for media
National and international media only
Regional or local media only
Names of two references with email or phone contact information. If you have references from current List members, please include them.
Preferred method of contact?
Contact information: Email
Enter your email address here if this is your preferred method of contact, and please answer AT LEAST ONE of the contact questions (cell/office/other contact information options follow):
Contact information: Cell Phone
Contact information: Office Phone
Contact information: Home/Other Phone
Please do not list fax numbers.
If you have a related website you'd like to list, please enter here
Area(s) of clinical expertise:
Select only areas where you would feel qualified to comment on the record and enter subspecialty under "Other" and you may elaborate further under the question below "Description of Interests"
Physical Medicine & Rehabilitation
Preventive Medicine & Public Health
Other area(s) of expertise
Critical appraisal, research methodology
Drug and device approval
Ethics and conflicts of interest
Health disparities, Social medicine
Health systems, insurance, politics of healthcare
Medical investigative journalism
Description of interests/expertise
If you want to elaborate on your areas of interest, research or expertise, do so here (optional):
Are you already a list member?
Do you want to be on (or remain on) The List?
YES: I want to be on The List, and I affirm that I do not have and have not received any financial support in any form from pharmaceutical or medical device manufacturers or insurers during the past five years, nor do I have any affiliations with or financial involvement (eg, employment, expert testimony, consultancies, honoraria, stock ownership or options, grants or patents received or pending, royalties) with any organization with a financial interest in or financial conflict with any drug or medical device or remedy (approved or unapproved) and I affirm that I will notify Jeanne Lenzer (
) if that changes
YES: However, I have the following disclosures listed under "Disclosures" below and I will disclose those conflicts whenever I am contacted for interviews
NO: I am currently on The List and can no longer serve as an expert
Disclosures: List disclosures for eligibility to be listed on Page 2.
If you are uncertain about whether your disclosures comprise a conflict of interest, simply list here and the panel will respond. If you have no disclosures to make, please LEAVE THIS QUESTION BLANK.
Questions or Comments?
A copy of your responses will be emailed to the address you provided.
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