(Form 2) Japanese Society of Physical Fitness and Sports Medicine Presentations at annual meetings/regional meetings䠖䠖 Declaration of Conflict of Interest by Self-report Speaker’s name:㻌 㻌㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 (Membership number:㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 ) Speaker’s affiliation:㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 Subject of the presentation:㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 (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㻌 䞉㻌 No Yes㻌 䞉㻌 No Yes㻌 䞉㻌 No Yes㻌 䞉㻌 No Yes㻌 䞉㻌 No Yes㻌 䞉㻌 No Yes㻌 䞉㻌 No Yes㻌 䞉㻌 No Yes㻌 䞉㻌 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)
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