(Format 1-1 for Journals)

Japan Society of Perinatal and Neonatal Medicine

Conflict of Interest Self-Report by Presenter/Author

To: President, Japan Society of Perinatal and Neonatal Medicine

Date of Report (AD) (mm)/(dd)/(yyyy)

□ Lead Author □ Study Representative (check the relevant column)

*Check both columns if the Lead Author is the same as the Study Representative.

Name (Member No.) ( )

Title of Paper/Study

Coverage: Clinical Study Period: The year (January to December) before contribution

*See Article 2 of the Detailed Rules for Conflict of Interest Guidelines given in JSPNM Homepage

Item / Status / If present, enter the enterprise name, etc.
(1) Reward
See Article 2 (1), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(2) Profits from stock
See Article 2 (2), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(3) Patent royalty
See Article 2 (3), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(4) Lecture fee
See Article 2 (4), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(5) Reward for manuscript
See Article 2 (5), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(6) Total towards study expenses, subsidy, etc.
See Article 2 (6), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(7) Total scholarship (promotional) award, etc.
See Article 2 (6), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(8) Other rewards (tours, gifts, etc.)
See Article 2 (7), Conflict of Interest Guidelines Detailed Rules / Present/Absent

(This report shall be stored for 2 years after publication of the paper)

Date of receipt (mm)/(dd)/(yyyy)
Receipt No.

(Format 1-2 for Meetings)

Japan Society of Perinatal and Neonatal Medicine

Conflict of Interest Self-Report by Presenter

To: President, Japan Society of Perinatal and Neonatal Medicine

Date of Report (AD) (mm)/(dd)/(yyyy)

□ Lead Presenter □ Study Representative* (check the relevant column)

*Check both columns if the Lead Presenter is the same as the Study Representative.

Name (Member No.) ( )

Title of Presentation

Coverage: Clinical Study Period: The year (January to December) before presentation title registration

*Details of each item are given in Article 2 of the Detailed Rules for Conflict of Interest Guidelines in JSPNM Homepage

Item / Status / If present, enter the enterprise name, etc.
(1) Reward
One million yen or more in a year received from a single enterprise/corporation / Present/Absent
(2) Profits from stock
Annual profits amounting to one million Yen or more from the stock of a single enterprise or possession of 5% or more of the total stock of the enterprise / Present/Absent
(3) Patent royalty
Annual royalty amounting to one million Yen or more received from a single patent right / Present/Absent
(4) Lecture fee
500,000 Yen or more in a year received from a single enterprise/corporation / Present/Absent
(5) Reward for manuscript
500,000 Yen or more in a year received from a single enterprise/corporation / Present/Absent
(6) Total towards study expenses, subsidy, etc.
Two million Yen or more in total in a year for a unit (course, specialty, laboratory, etc.) sharing the study expenses received from a single enterprise/corporation / Present/Absent
(7) Total scholarship (promotional) award, etc.
Two million Yen or more in total in a year for a unit (course, specialty, laboratory, etc.) sharing the scholarship donations received from a single enterprise/corporation / Present/Absent
(8) Other rewards (tours, gifts, etc.)
50,000 Yen or more in a year received from a single enterprise/corporation / Present/Absent

(This report shall be stored for 2 years after publication of the abstract)

Date of Receipt (mm)/(dd)/(yyyy)
Receipt No.

(Format 1-3)

Japan Society of Perinatal and Neonatal Medicine Perinatal Medicine Symposium

Conflict of Interest Self-Report by Presenter

To: President, Japan Society of Perinatal and Neonatal Medicine

Date of Report (AD) (mm)/(dd)/(yyyy)

□ Presenter □ Study Representative* (check the relevant column)

*Check both columns if the Presenter is the same as the Study Representative.

Name (Member No.) ( )

Title of Presentation

Coverage: Clinical Study Period: The year (January to December) before presentation title registration

* See Article 2 of the Detailed Rules for Conflict of Interest Guidelines

Item / Status / If present, enter the enterprise name, etc.
(1) Reward
See Article 2 (1), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(2) Profits from stock
See Article 2 (2), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(3) Patent royalty
See Article 2 (3), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(4) Lecture fee
See Article 2 (4), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(5) Reward for manuscript
See Article 2 (5), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(6) Total towards study expenses, subsidy, etc.
See Article 2 (6), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(7) Total scholarship award (promotional) donation, etc.
See Article 2 (6), Conflict of Interest Guidelines Detailed Rules / Present/Absent
(8) Other rewards (tours, gifts, etc.)
See Article 2 (7), Conflict of Interest Guidelines Detailed Rules / Present/Absent

(This report shall be stored for 2 years after publication of the abstract)

Date of Receipt (mm)/(dd)/(yyyy)
Receipt No.

(Format 2)

Conflict of Interest Self-Report by Officer or the Like

[One-year period (January to December according to a calendar year in AD)

before assuming office]

To: President, Japan Society of Perinatal and Neonatal Medicine

Date of Report (AD） (mm)/(dd)/(yyyy)

Name of Reporter (Member No.) ( ）

Unit (Institution, Course/Specialty)/Title

Title at the JSPNM: □ President □ Vice President □ Director □ Auditor

□ Professional Meeting Chairperson

Name of the Specific Committee : □ Scientific Committee Chairman

□ Publication/Editorial Committee Chairman

□ Ethics Committee Chairman

□ Perinatal Medicine Symposium Management Committee Chairman

I hereby make a declaration any conflict of interest with the enterprise or for-profit corporation related to the businesses of the JSPNM.

1. Presence/absence of my role as an officer or advisor at an enterprise/for-profit corporation and the reward for such a role (□Present/□Absent)

(Enter the role for which the annual reward from a single enterprise/corporation is one million Yen or more)

Name of Enterprise/Corporation / Role (Officer, Advisor, etc.) / Amount Class
1
2
3

Amount Class: (1) from one million to less than 5 million Yen, (2) 5 million Yen or more

2. Possession of stock and profits from the stock (profits from the stock during the latest one-year period) (□Present/□Absent)

(Enter the stock of a single enterprise yielding one million Yen or more profits in a year or the name of the enterprise in which you possess 5% or more of the total stock)

Name of Enterprise / No. of Shares / Stock Price per Share at the Time of Report / Amount Class
1
2

Amount Class: (1) from one million to less than 5 million Yen, (2) 5 million Yen or more

3. Reward paid as patent royalty by an enterprise/for-profit corporation (□Present/□Absent)

(Enter the royalty amounting to one million yen or more in a year per a single patent right)

Name of Enterprise/Corporation / Patent Name / Amount Class
1
2

Amount Class: (1) from one million to less than 5 million Yen, (2) 5 million Yen or more

4. Daily allowance (lecture fee, etc.) covering the time/labor needed for participation (presentation) in/at the meeting received from an enterprise/for-profit corporation

(Enter the allowance amounting to 500,000 Yen or more in total in a year paid by a single enterprise/corporation) (□Present/□Absent)

Name of Enterprise/Corporation / Amount Class
1
2
3

Amount Class: (1) from 500,000 to less than 2 million Yen, (2) 2 million Yen or more

5. Reward for the manuscript of a leaflet, etc., received from an enterprise/for-profit corporation (□Present/□Absent)

(Enter the reward amounting to 50,000 Yen in total in a year paid from a single enterprise/corporation)

Enterprise/Corporation Name / Amount Class
1
2

Amount Class: (1) 500,000 to less than 2 million Yen, (2) 2 million Yen or more

6. Study expenses paid by an enterprise/for-profit corporation (□Present/□Absent)

(Enter the reward amounting to 2 million Yen or more in total in a year received for a single clinical study (clinical trial, collaborative study, assigned research, etc.))

Name of Enterprise/Corporation / Study Expense Category / Amount Class
1
2
3

Study Expense Category: (1) clinical trial, (2) industry-academic collaborative study, (3) assigned research

Amount Class: (1) from 2 million to less than 10 million Yen, (2) 10 million Yen or more

7. Scholarship (promotional) donation from an enterprise/for-profit corporation (□Present/□Absent)

(Enter the donation amounting to 2 million yen or more in total in a year received by the reporter or by the course/specialty or laboratory to which the reporter belongs) from a single enterprise/corporation

Name of Enterprise/Corporation / Amount Class
1
2
3

Amount Class: (1) from 2 million to less than 10 million Yen, (2) 10 million Yen or more

8. Other rewards (tours, gifts, etc. having no direct relationship to the study) (□Present/□Absent)

(Enter the reward amounting to 50,000 Yen or more in a year received from a single enterprise/corporation)

Name of Enterprise/Corporation / Nature of Reward / Amount Class
1
2
3

Amount Class: (1) from 50,000 to less than 200,000 Yen, (2) 200,000 Yen or more

(This declaration shall be stored for 2 years from expiration of the officer’s term or retirement from the office of committee chairman)

Date of Receipt (AD) (mm)/(dd)/(yyyy)
Receipt No.

1