COI Self-Disclosure Please disclose COI status and name of company or organization involved with the subject matter of your presentation topic. COI status must be disclosed for the preceding three year from the time of abstract submission. However, concerning items 6 and 7, if clinical fundingor scholarship funds related to the publication of research results are provided by a business, organization or group, to the author, or his/her affiliated department or field, these must also be disclosed. Applicable or related If yes, list the name(s) of company Type COI or organization Author Yes No Consultancy Annual income from a single company or 1 Spouse etc. organization, as an officer or consultant, which Yes exceeds an annual total of 1,000,000 yen No Author Stock /Stock Options Yes Profit from stocks of one single company or No 2 organization which exceeds an annual total of Spouse etc. 1,000,000 yen, or 5% or more of total shares of one Yes company/organization No Author Patent royalties/licensing fees Yes No Patent royalties/licensing fees which exceeds an 3 annual total of1,000,000 yen from a single Spouse etc. Yes company or organization No Remuneration (e.g. lecture fees) Author Yes Remuneration for attending meetings No 4 (presentations), paid for the time and effort of the activity, which exceeds an annual total of 500,000 yen, per company or organization Manuscript fees Author Yes Manuscript fees for writing of pamphlets etc. , 5 No which exceeds an annual total of 500,000 yen per company or organization annually from one commercial entity
COI Self-Disclosure Please disclose COI status and name of company or organization involved with the subject matter of your presentation topic. COI status must be disclosed for the preceding three year from the time of abstract submission. However, concerning items 6 and 7, if clinical fundingor scholarship funds related to the publication of research results are provided by a business, organization or group, to the author, or his/her affiliated department or field, these must also be disclosed. Type Applicable or related COI If yes, list the name(s) of company or organization 1 Consultancy Annual income from a single company or organization, as an officer or consultant, which exceeds an annual total of 1,000,000 yen Author Yes No Spouse etc. Yes No 2 Stock /Stock Options Profit from stocks of one single company or organization which exceeds an annual total of 1,000,000 yen, or 5% or more of total shares of one company/organization Author Yes No Spouse etc. Yes No 3 Patent royalties/licensing fees Patent royalties/licensing fees which exceeds an annual total of1,000,000 yen from a single company or organization Author Yes No Spouse etc. Yes No 4 Remuneration (e.g. lecture fees) Remuneration for attending meetings (presentations), paid for the time and effort of the activity, which exceeds an annual total of 500,000 yen, per company or organization Author Yes No 5 Manuscript fees Manuscript fees for writing of pamphlets etc. , which exceeds an annual total of 500,000 yen per company or organization annually from one commercial entity Author Yes No
24JACR_AbstractSubmissionForm.docx