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Disclosure Statement of Conflict of Interest (COI) at the 62nd Annual Meeting of the Japanese Society of NeurologyTo Executive President, Japanese Society of NeurologyName of declarer: Company/organization (institution, class/medical department) / Job title: Category of the lecture title registered □Symposium □Educational Program (Tick the applicable box) □Sponsored Seminar □Plenary Lecture□Free Paper (Oral, Poster)Lecture title: If there is any company with which the lead presenter has a conflict of interest required to be disclosed in connection with the subject of the lecture to be given, state the relevant facts in the following respective items.　(Declare any conflict of interest that existed within the one-year period prior to the registration of the abstract)ItemRelevant partyIf yes, state the name of such company or organization(1) Does the declarer/relative serve or has the declarer/relative served as director or advisor of a company or for-profit organization? If yes, state the value of the remuneration received for a period of one year. (State any compensation of 1 million JPY or more received within a period of one year from one company or organization)(Declarer)lYes　 No　(Relative)Yes　 No　(2) Does the declarer/relative hold or has the declarer/relative held any shares in the company concerned? If yes, state the profit earned from such shares. (State any profit of 1 million JPY or more earned within a period of one year from shares in one single company and any profit earned within a period of one year from shares in one single company in the event of 5% or more of the company's shares being held by the declarer/relative)(Declarer) Yes　 No　(Relative) 　　　　　　　　 Yes　 No　(3) Has the declarer/relative received any remuneration from a company or for-profit organization as the fee for the use of a patent? (State any annual remuneration of 1 million JPY or more received within a period of one year as the fee for the use of one single patent)(Declarer) Yes　 No　(Relative) Yes　 No　(4) Has the declarer received from a company or a for-profit organization any daily allowance or lecture fee paid for his/her attending a meeting (making a presentation) on the basis of the research time sacrificed and the service provided? (State any annual compensation totaling 500,000 JPY or more received within a period of one year from one company or organization)(Declarer) llllllllll Yes　 No　(5) Has the declarer received from a company or a for-profit organization any manuscript fee paid for writing brochure text? (State any remuneration totaling 500,000 JPY or more received within a period of one year from one company or organization)(Declarer) llllllllll Yes　 No　(6) Has the declarer received from a company or a for-profit organization any research fee (paid in connection with commissioned research or joint research)? (State any remuneration totaling 2 million JPY or more received within a period of one year from one company or organization)(Declarer) llllllllll Yes　 No　(7) Has the declarer received any study encouragement donation (encouragement donation) from a company or a for-profit organization? (State any study encouragement donation totaling 2 million JPY or more received within a period of one year from one company or organization)(Declarer) llllllllll Yes　 No　(8) Does the declarer belong or has the declarer belonged to any seminar funded by a company or a for-profit organization? (State if the declarer Is a member of any seminar group funded by a company or a for-profit organization)(Declarer) llllllllll Yes　 No　(9) Has the declarer received any non-research-related benefits such as travel and gifts? (State any benefit worth 50,000 JPY or more received within a period of one year from one company or organization)(Declarer) llllllllll Yes　 No　Declarations concerning (6) and (7) are required to be made if the lead presenter himself/herself or the medical unit (seminar group, field group) or research group to which the lead presenter belongs has been given, in connection with a research results presentation, the payment of research expenses or study encouragement donation by a company/organization with which the declarer or his/her relative has a conflict of interest required to be disclosed.Date of declaration (Western calendar): Signature of declarer: ................
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