(Form 2)
Japanese Society of Physical Fitness and Sports Medicine
Presentations at annual meetings/regional meetings：
Declaration of Conflict of Interest by Self-report
Speaker’s name:
(Membership number:
)
Speaker’s affiliation:
Subject of the presentation:
(All of the authors of the presentation listed above are required to submit a report on any conflicts of
interest individually. Please thoroughly describe the conflicts of interest with corporations or other
forms of entities associated with the presentation, which can be traced back three years from the
registration of the subject.)
Item
1.
2.
3.
4.
5.
6.
7.
8.
9.
Applicability
Amount of compensation
One million yen or more in one year from one
enterprise or organization
Stock profit
One million yen or more in one year from one
enterprise or organization or possessing 5% or
more of total shares of said stock
Patent royalty
One million yen or more in a year for one patent
Lecture Remuneration
500,000 yen or more in one year from one
enterprise or organization
Manuscript Remuneration
500,000 yen or more in a year from one enterprise
or organization
Total amount of research funding/subsides, etc.
Total of two million yen or more in one year paid
by one enterprise or organization to the affiliated
department that shares research expenditure
Sum amount of incentives (promotions),
donations, etc.
Total of two million yen or more in one year paid
by one enterprise or organization to the affiliate
department that shares the scholarship donation
Endowed course provided by an enterprise, etc.
(Fill in if you belong to an endowed course, etc.,
provided by an enterprise)
Provisions such as trips, gift items, etc., from an
enterprise etc. with a conflict of interest
50,000 yen or more in one year from one
enterprise or organization
If yes, please provide the name
of the author, enterprise, etc.
Yes ・ No
Yes ・ No
Yes ・ No
Yes ・ No
Yes ・ No
Yes ・ No
Yes ・ No
Yes ・ No
Yes ・ No
(This document will be kept for two years from the day of the presentation of the paper you authored
entirely or partially.)
(Date of Declaration)
year
month
date
(Signature)