Application of COI in Conferences
Application Screen
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Name of Applicant
(Required)
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Affiliation of Applicant
(Required)
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E-mail Address of Applicant
(Required)
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Name of Conference
(Required)
Year
Annual Meeting
International Symposium
■
Subject Registration Number
(Required when you choose Annual Meeting)
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Full Names of All Authors
(Required)
* Please list all authors: the first author(s) and co-author(s).
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Affiliation of Presenter
(e.g., ABC University Cardiovascular Center)
(Required)
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Abstract Title
(e.g., Relationship between A and B)
(Required)
Please refer to
Disclosure of Conflict of Interest (COI) in Conferences and/or Official Journals of the Japanese Society of Hematology (JSH)
and answer the following items.
(Required)
All authors are required to disclose COI status with any business enterprises, commercial entities or for-profit organizations related to the medical research, irrespective of the subject of your presentation, currently or during the past three years (hereafter referred to as “Commercial Entity” or “Commercial Entities”).
(This form will be kept for three years after the time of abstract submission.)
(The content of your report will not be disclosed to a third party unless otherwise legal or social needs request disclosure.)
Criteria 6 and 7 shall be applicable when research funds, subsidy or donation are provided from Commercial Entities to any presenter (presenters) or the course, the field, or the department to which a presenting author (and all co-authors) belongs.
Item
Applicability
If “Yes”, list author(s) name(s)
(company name(s))
1
Employment or administrative position, or advisory role in Commercial Entities.
if compensation from a single Commercial Entity is 1,000,000 yen or more per year.
Yes
No
2
Stock or any other interest ownership and/or options in Commercial Entities (the “Interest”).
if profit (total of dividend or any equivalent thereto and gain on sales) of 1,000,000 yen or more per year from Interests of one Commercial Entity, or ownership of 5% or more of total Interests.
Yes
No
3
Patent royalties from one Commercial Entity.
if the royalty fee is 1,000,000 yen or more per year.
Yes
No
4
Fees (e.g., honoraria, lecture fees) paid from one Commercial Entity, for the time and/or labor of a researcher who attended, expressed opinions or made presentations at meetings.
if the total amount of manuscript fees is 500,000 yen or more per year.
Yes
No
5
Manuscript fees for promotional materials (e.g., brochures, articles) paid by one Commercial Entity.
if the total amount of manuscript fees is 500,000 yen or more per year.
Yes
No
6
Research funds paid for medical research (e.g., collaborative research, funded research, clinical trial) by one Commercial Entity.
if the sum of which a presenter (presenters) is in the position to decide how to use is 1,000,000 yen or more per year.
Yes
No
7
Subsidy or donation from one Commercial Entity to a presenting author (and co-authors) or the course, the field, or the department to which he/she (they) belongs.
if the sum of which he/she (they) is in the position to decide how to use is 1,000,000 yen or more per year.
Yes
No
8
Donated fund laboratory provided by one Commercial Entity or Commercial Entities.
if the sum of which a presenting author (and co-authors) is in the position to decide how to use in the laboratory is 1,000,000 yen or more per year.
Yes
No
9
Any benefits including trips, travel, or gifts, which are not directly related to research, provided by one Commercial Entity.
if the sum of such benefits is 50,000 yen or more per year.
Yes
No
Confirm
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