Annual Autumn Meeting(JDDW) Conflict of Interest Disclosure Statement

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COI Disclosure by Presenters (including Co-Presenters) for annual meeting (JDDW) Registration

Please enter the names of companies, organizations, etc. that are in a COI relation with presenters regarding the presentation at annual meeting (JDDW) for each item on the form below. When you have completed, click on the “Go to Confirmation Page” button below.
This COI disclosure will be maintained for up to two years after the presentation.
Presenters are required to disclose any state of conflict of interest existing at any time during a period of three years prior to the abstract registration.

As from January 2016, disclosure of conflict of interest is required of lead presenters as well as co-presenters. The person with responsibility over the presentation (the lead presenter or the corresponding speaker) should prepare and make the COI disclosure. (Applicability on COI disclosure should be based not on the sum that is the aggregate of all presenters, including co-presenters, but on the sum received or gained by individual presenters. If the sum received or gained by any individual presenters is or exceeds the applicable amount in each category, it must be disclosed).

RequiredPresentation Registration No.
(five digits)
RequiredSession Title
Membership No. of the Person with Responsibility over the Presentation
(five digits)
RequiredName of the person with responsibility over the presentation
Last name
 First name

RequiredName(s) of Presenter(s)
Co-presenters (*indicate the names of all co-presenters)		 Co-Presenters

If Yes: Indicate the names of all presenters in the space below.
RequiredE-Mail (of the person with responsibility over the presentation)

(please enter again to make sure)

*"Family Member" means the presenter's spouse, first-degree relatives, and other individuals living on the same income or sharing profits from common assets as the presenter.

Category
Matters to be disclosed in relation to the presenters and their family members		 RequiredApplicability
(Please check either Applicable/Not Applicable for each item)		 If applicable, indicate the names of the companies/organizations
1. Board member/advisor of a company or for-profit organization and the amount of compensation
(Applicable if annual compensation from any one company or organization is ¥1 million or more)		 All Presenters


Family Member


2. Ownership of corporate stocks and profits earned from the stocks
(Applicable if an annual profit from one company's stock is ¥1 million or more or you or your relative have ownership of 5% or more of the company's outstanding shares)		 All Presenters


Family Member


3. Patent royalties received from a company or for-profit organization
(Applicable if an annual loyalty payment received is ¥1 million or more for use of one patent)		 All Presenters


Family Member


4. Per diem, honorariums, etc. paid by a company or for-profit organization for the time and energy spent by a researcher to attend or give a presentation or advice at a meeting
(Applicable if a total amount of ¥500,000 or more of per diem, honorariums, etc. is received from one company or organization in a year)		 All Presenters


5. Fees paid by a company or for-profit organization for writing a pamphlet, etc.
(Applicable if a total amount of ¥500,000 or more in fees is received from one company or organization in a year)		 All Presenters


6. Research grants from a company or for-profit organization (for joint research, commissioned research, clinical trials), etc.
(Applicable if research grants are awarded by one company or organization for medical research and the total contracted amount for research actually allocated　for the presenter to essentially have discretion over their use is ¥1 million or more in a year)		 All Presenters


7. Scholarship grants from a company or for-profit organization
(Applicable if scholarship grants are awarded by one company or organization to the presenter or to the chair, field, or laboratory the presenter is affiliated with and the total amount of the grants actually allocated for to the presenter to essentially have discretion over their use is ¥1 million or more in a year)		 All Presenters


8. Endowed chair from a company or for-profit organization
(Applicable if you are affiliated with an endowed chair from a company, etc.)		 All Presenters


9. Trips and other gifts unrelated to research, education, or healthcare
(Applicable if a total amount of ¥50,000 or more is provided from one company or organization in a year)		 All Presenters


Category
Institutional COI related to the research institute or division (e.g. a research institute, hospital, faculty, center, etc.) the presenters are affiliated with		 Applicability*
(Please check either Applicable/Not Applicable for each item)		 If applicable, indicate the names of the companies/organizations
10. Research grants from a company or for-profit organization (Applicable if research grants are awarded by one company or organization to the research institute or division you are affiliated with or to the head of the research institute or division and the total amount of the grants that the research institute or division or its head essentially has discretion over their use is \10 million or more in a year) All Presenters


11. Donations from a company or for-profit organization (Applicable if donations are awarded by one company or organization to the research institute or division you are affiliated with or to the head of the research institute or division and the total amount of the donations that the research institute or division or its head essentially has discretion over their use is \2 million or more in a year) All Presenters


12. Others (Applicable if the research institute or division you are affiliated with or the head of the research institute or division owns a company’s stocks (5% or more of the issued shares of the company), has received patent royalties from a company or organization, or has any investment outstanding in a company or organization) All Presenters


*Make sure you have filled out all of the items for registration of your presentation in JDDW.