Japan Gastroenterological Endoscopy Society – Title Registration

Conflict of Interest Disclosure Statement by Lead Presenter

Title Registration Number / Name of Lead Presenter
Title of Presentation

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◇ In connection with the above-mentioned presentation, report the names of any companies and organizations and state the Conflict of Interest for each entry.

※ Any COI during the past 36 months should be disclosed at the time of Abstract registration.

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Entry / Status / If yes, provide the name of the company and/or organization
1  Postemployment/leadership position/advisory role in companies or profit-oriented organizations, and compensation related to the post
（More than one million yen per year from one company/organization） / Self:
Yes/No
Family:
Yes/No
② Stock ownership and profits from stock ownership
（More than one million yen or 5% per year from one company/organization） / Self:
Yes/No
Family:
Yes/No
③ Patent royalties/licensing fees paid by companies and profit-oriented organizations
（More than one million yen per patent per year） / Self:
Yes/No
Family:
Yes/No
④ Honoraria (e.g. lecture fees) paid by companies and profit-oriented organizations to compensate for attendance (presentation) at meeting/s
（More than half a million yen in total per year from one company/organization） / Self:
Yes/No
⑤ Manuscript fees paid by companies and profit-oriented organizations for writing promotional material (e.g. brochures)
（More than half a million yen in total per year from one company/organization） / Self:
Yes/No
⑥Research funding (clinical trial, sponsored or funded research, collaborative research etc.) provided by companies and profit-oriented organizations
（More than one million yen in total per year from one company/organization） / Self:
Yes/No
⑦ Scholarship contributions from companies and profit-oriented organizations
（More than one million yen in total per year from one company/organization） / Self:
Yes/No
⑧ Study group sponsorship by companies and profit-oriented organizations
（The researcher belongs to such a study group） / Self:
Yes/No
⑨ Payments from companies and profit-oriented organizations for anything unrelated to research, education, or medical practice
（More than fifty thousand yen in total per year from one company/organization ） / Self:
Yes/No

※Report on the lead presenter him/herself, his/her spouse, first-degree relatives, and anyone who shares his/her income and wealth.

NOTE: This COI Disclosure Statement will be kept on file for 2 years after the meeting presentation. However, any statements relating to rejected presentations will be destroyed immediately and will not be returned to the presenter.

Date of disclosure :

Lead presenter (signature)

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