JAPANESE ACADEMY OF CLINICAL PERIODONTOLOGY DISCLOSURE STATEMENTREGARDING DUAL COMMITMENT
The Japanese Academy of Clinical Periodontology enjoys an excellent reputation in the dental community
and the public. This reputation depends in large measure upon the confidence the members and thepublic have in its integrity. In order to ensure balance, independence, objectivity, and scientific rigor inscientific/educational activities, the Academy requires disclosure of potential conflicts of interest by its
Annual Meeting speakers. Potential conflicts of interest include relationships with pharmaceuticalcompanies, biomedical device manufacturers or distributors, academic or research institutions, or others
whose products or services may be considered to be related to the subject matter of thescientific/educational activity.
It is recognized that speakers have personal, business, and professional interests or commitments, someof which may have the potential to create conflicts. The principal intent of requiring disclosure is not toprevent an individual speaker with dual commitments from involvement, in so much as that evaluation of
the speaker’s relationships may be observed in light of full disclosure of related information.
SUMMARY OF OPERATING PRINCIPLES GOVERNING DISCLOSURE
OF DUAL COMMITMENT
1. The expression “dual commitment” describes the dilemma faced by speakers when their responsibility
to remain unbiased may be compromised or perceived to be compromised by a simultaneouscommitment to commercial interests related to the subject of a specific scientific/educational activity.
“Conflict of interest” refers to a degree of dual commitment that may be strong enough to produce
reservations regarding potential loss of objectivity.
2. Dual commitments include, but are not limited to:•Financial Interest - ownership, stocks, past or present employment of immediate family, royalties,etc.

•Consulting - paid or unpaid (including, but not limited to, honorarium, travel and/or otherexpenses).

•Special Customer Preferences.

•Direct Research Contract.

•

Research through University - indirect (including, but not limited to, honorarium, travel or otherexpenses).

3. The JACP requires disclosure of dual commitments. In determining the significance of a dual
commitment, the JACP considers the following:•••

Scope of relationship or commitment.
Frequency and timing (i.e. whether past or recent, occasional or long-standing).
Number (i.e. a single, exclusive relationship rather than multiple, competing relationships).

DISCLOSURE OF DUAL COMMITMENT
I have read the operating principles governing dual commitment and potential conflict of interest. As it
pertains to my potential role as a Japanese Academy of Clinical Periodontology Annual Meeting presenter,I declare that:_____ I have no dual commitment (as previously defined in this document).
_____ I may have an area of dual commitment as stipulated below.

Type of Commitment

Company

Financial Interest_________________________________________

Consultant_________________________________________

Special Customer Preferences_________________________________________

Direct Research Contract_________________________________________

Research through University_________________________________________

Other (please explain)_________________________________________

If my interests or commitments change during the year, I agree to file an amended
disclosure statement at that time.

Name (please print)

Signature

Date

Please return this page with your abstract
as soon as possible. Thank you.