JOURNAL of Echocardiography (JEcho)
Conflict of Interest (COI) Disclosure Form
Manuscript Title:
Each author is required to complete and return this form to the corresponding author.
(Please DO NOT send to JSE Society Office)When authors submit a manuscript, they are responsible for disclosing all financial and personal relationships that might bias theirwork. To prevent ambiguity, authors must state explicitly whether potential conflicts do or do not exist. Each author must completeand submit this COI disclosure form, and the corresponding author should submit all the COI disclosure forms when submitting amanuscript. Each author must indicate whether or not they have a financial relationship with any organization that sponsored theresearch, or is associated with any product or procedure that is mentioned in the article. For each source of funds, both the research
funder and the grant number should be given. The form must be submitted to the journal’s editorial office by uploading it as a PDF
file.
Conflict of interest statements should be present on every manuscript before the References section. The statements should list eachauthor separately by name. Sample wording is as follows:
Conflict of interest: John Smith declares that he has no conflict of interest. Paula Taylor has received research grants from Drug
Company A. Mike Schultz has received a speaker honorarium from Drug Company B and owns stock in Drug Company C.
If multiple authors declare no conflict, this can be done in one sentence:
Conflict of interest: John Smith, Paula Taylor, and Mike Schultz declare that they have no conflict of interest.
If you, your spouse, a relative in the first degree, or any other person who shares income or assets, has any of the listed relationships
with a commercial entity that has an interest in the subject matter in your manuscript, please circle “yes” and provide details. If
the listed relationship does not apply to you or your family member, circle “No”.
Category
1. Position as an officer or advisor of acompany or for-profit organization andremuneration amount(¥100,000 or US $ 1,000, or more)*
2. Stock ownership and profit resulting fromthe stock(¥100,000 or US $ 1,000, or more/
ownership of 5% or more of total shares)
3. Remuneration paid as patent royalties orlicensing fees from companies or for-profit
organizations(¥100,000 or US $ 1,000, or more)
4. Honoraria (such as lecture fees) paid by acompany or for-profit organization ascompensation(¥50,000 or US $ 500, or more)
5. Manuscript fees paid from companies orfor-profit organizations(¥50,000 or US $ 500, or more)
6. Research funding from companies orfor-profit organizations(¥200,000 or US $ 2,000, or more)
7. Other remuneration (travel, gifts, or
in-kind payments not directly related toresearch)(¥50,000 or US $ 500, or more)*Amount of all items: per a year

Applicability
Yes/NoIf yes, record the following details for each company ororganization.
Company or organization name:
Position:
Company or organization name:

Yes/NoCompany or organization name:
Yes/NoPatent name:Company or organization name:

Yes/NoCompany or organization name:
Yes/NoCompany or organization name:
Yes/NoName of clinical research:
Company or organization name:

Yes/NoPrint name:Signature:

Date (YY/MM/DD):

All of the forms from each author need to be uploaded online and submitted with the manuscript at the time ofsubmission by the corresponding author.

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