Conflict of Interest Declaration (Questionnaire)for FY2022 and FY2023
Q1: Are you engaged in any industry-academia-government collaboration
activities as of the date of this declaration? Or are you planning to beengaged in such activities from now onward?
If so (currently engaged or planning to), proceed to Q2.
If not (not currently engaged, nor planning to), you do not need to answer thefollowing questions. Put (enter) your name at the end of the answer sheet andsubmit it.
In this questionnaire, “industry-academia-government collaboration activities” aredefined as: any of the following activities carried out with collaborative partners(companies and other profit-making enterprises or organizations engaged inprofit-making activities)*.
* Except for national and local governments, universities, inter-university
research institutes, colleges of technology, national research and development
institutes, public testing and research institutes.
Joint research: research under a joint research agreement in which Kyushu
University and a collaborative partner work together on a common
subject (acceptance of a donation does not fall under thisdefinition).
Sponsored research: research under a sponsored research agreement (includingclinical trials) which Kyushu University carries out independently as
commissioned by a collaborative partner (acceptance of a donation
does not fall under this definition).
Academic consulting: activity under an academic consulting agreement in which
Kyushu University supports the business and activities of a collaborative
partner, by providing guidance and advice based on its expert
knowledge in education, research, and technology.
Clinical research: clinical trials, clinical tests, and other medical and health research
involving human subjects carried out for the purposes of improving
methods for preventing, diagnosing and treating diseases,
understanding the cause and pathology of diseases, and improving thequality of life of patients in medical care.
Technology transfer: licensing and transfer to a collaborative partner of intellectual
property in which you have a stake.
Donation: acceptance of a donation upon application from a collaborative partner.
Side job/position: assumption of a position of a technical adviser and so forth for acollaborative partner (excluding assumption of a position as a part-time
doctor at a medical institution).
From Q2 to Q8, please give answers for each collaborative partner.

Q2: Write name of the collaborative partner.
Q3: Does the collaborative partner fall within the category of a
Kyushu-University-originated venture company (i.e., a company
established for the purpose of commercialization of research results

obtained at Kyushu University)?
Q4: Which kind of industry-academia-government collaboration activities
are you engaged in (or are you planning to be engaged in) with thecollaborative partner? Choose all that apply from among the options on
the answer sheet.
Q5: During FY2022 and FY2023, when Kyushu University placed an orderwith the collaborative partner for commodities or services worth
JPY5,000,000 or more (tax included), did you take part in the process of
selecting the kind, type, and other particulars of the commodities orservices or the supplier thereof? Or do you have any plan to take part insuch process in FY2023? If so, specify the details.
Q6: During FY2022 and FY2023, did you accept a donation of JPY2,000,000
or more from the collaborative partner? Or do you have any plan toaccept such donation in FY2023? If so, specify the amount.
Q7: During FY2022 and FY2023, did you or your spouse obtain any financial
benefits (including provision of commodities, but excluding donations
accepted by Kyushu University) worth JPY1,000,000 or more (taxincluded)? Or do you have any plan to obtain such benefits in FY2023? If
so, specify the details.
The term "spouse" as used herein is defined as your spouse or relative within thesecond degree of kinship who shares the same livelihood with you.
This definition also applies to Q8.

Q8: As of the date of this declaration, do you and your spouse hold equity inthe collaborative partner? If the collaborative partner is a public (listed)company, specify the holding ratio of five percent or more. If thecollaborative partner is a non-public (unlisted) company, specify theholding ratio regardless of its percentage. Or do you have any plan to holdequity? If so, specify the details.
The term "equity" as used herein is defined as stock, investment, share options(including stock options), beneficial interests, or the like.
The term “holding ratio” means the total equity held / the total equity issued ×100%(The result calculated in this formula can be larger than the actual ratio.)

This concludes the questionnaire. Put (enter) your name at the end of theanswer sheet before submitting it.