/ / (DD/MM/YYYY) Academic Journal “Physical Therapy Research (PTR)” Declaration Form for Conflict of Interest Each author of the research article should individually submit their declaration form. Any conflict of interest with companies, organizations, or associations that may be related to the contents of the article within the past 1 year of submission of the article should be described. 1. Information of the submitted article Title of the article: Name of the person who submitted the article (handwritten signature) : Affiliations: 2. Disclosure of conflict of interest Answer all the relevant questions given below based on the “Guidelines for disclosure of conflict of interest (COI)” Is it applicable If applicable, write names of Amount to you? the organizations, etc. 1. Executives and ・ 1,000,000 yen or more Yes No executive advisors 1,000,000 yen or more/5% ・ 2. Shareholders Yes No or more ・ 3. Patent license fees 500,000 yen or more Yes No 4. Daily allowances ・ 500,000 yen or more Yes No (Lecture fees, etc.) ・ 5. Manuscript Fee 500,000 yen or more Yes No ・ 6. Research fund 2,000,000 yen or more Yes No ・ 7.Research donation 2,000,000 yen or more Yes No If you belong to a endowed 8.Endowed laboratory ・ Yes No laboratory ・ 9. Other fees 50,000 yen or more Yes No *Information regarding the disclosure of conflict of interest should be listed at the end of the main text (before References) under the title “Conflicts of interest.” *If any author has any conflict of interest, list the author’s name and the conflict of interest. If the authors have no conflict of interest to declare, please include the following line: “There is no conflict of interest to disclose.
/ / (DD/MM/YYYY) Academic Journal “Physical Therapy Research (PTR)” Declaration Form for Conflict of Interest Each author of the research article should individually submit their declaration form. Any conflict of interest with companies, organizations, or associations that may be related to the contents of the article within the past 1 year of submission of the article should be described. 1. Information of the submitted article Title of the article: Name of the person who submitted the article (handwritten signature) : Affiliations: 2. Disclosure of conflict of interest Answer all the relevant questions given below based on the “Guidelines for disclosure of conflict of interest (COI)” Amount Is it applicable to you? If applicable, write names of the organizations, etc. 1. Executives and executive advisors 1,000,000 yen or more Yes ・ No 2. Shareholders 1,000,000 yen or more/5% or more Yes ・ No 3. Patent license fees 500,000 yen or more Yes ・ No 4. Daily allowances (Lecture fees, etc.) 500,000 yen or more Yes ・ No 5. Manuscript Fee 500,000 yen or more Yes ・ No 6. Research fund 2,000,000 yen or more Yes ・ No 7.Research donation 2,000,000 yen or more Yes ・ No 8.Endowed laboratory If you belong to a endowed laboratory Yes ・ No 9. Other fees 50,000 yen or more Yes ・ No *Information regarding the disclosure of conflict of interest should be listed at the end of the main text (before References) under the title “Conflicts of interest.” *If any author has any conflict of interest, list the author’s name and the conflict of interest. If the authors have no conflict of interest to declare, please include the following line: “There is no conflict of interest to disclose.
PTR%20Declaration%20Form%20for%20Conflict%20of%20Interest_20170317.docx