様式１A
The Japanese Society of Child and Adolescent Psychiatry
Self-reported Potential Conflict of Interest Disclosure Statement

Author’s name:
Manuscript No．
Manuscript Title:

Each author is required to complete and return this form to the corresponding author．
The corresponding author should upload the forms online

When submitting a revised manuscript to Japanese Journal of Child and Adolescent Psychiatry， all authors arerequired to disclose any financial relationship (within the past 36 months) with a company or organization that has aninterest in the subject matter or materials discussed in the manuscript． The matters requiring disclosure are outlined inthe JSCAP Conflict of Interest Policy (IV． Matters Requiring Disclosure)．
When a manuscript has been accepted for publication， all of the disclosures will appear in the article as a “Conflict ofInterest Statement” in Japanese Journal of Child and Adolescent Psychiatry as follows:
Conflict of Interest Statement
A (author name) serves as a consultant to Z (entity name); B’s spouse is chairman of Y; C received a research
grant from X; D received lecture fees from V; E holds a patent on U; F has been reimbursed by T for attendingseveral conferences; G received honoraria for writing promotional material for S; H has no conflict ofinterest．
If you， your spouse， or other immediate family member， has any of the listed relationships with a commercial
entity that has an interest in the subject matter in your manuscript， please refer it to the JSCAP’s definition forpotential conflict of interest which must be disclosed． And then， check the appropriate "Yes" box below and provide
details． If the listed relationship does not apply to you or your family member， check the appropriate "No" box．
You are required to disclose “Conflict of Interest Statement” on an annual basis forthe past 3 years.

Personal Financial Interests for a year fromArea(mm/yyyy) to(mm/yyyy).

Yes

If Yes: List the name(s)of authors and/Nocompany/organization(s) and use as much space as necessary

1． Employment/Leadership position/Advisory□Yesrole (1,000,000 yen* or more)□No

2． Stock ownership (Profit of 1,000,0000 yen□Yesor more / ownership of 5% or more of total□Noshares)
3． Patent royalties / licensing fees

□Yes(1,000,000 yen or more)□No

4． Honoraria (e.g. lecture fees)□Yes(500,000 yen or more)□No

5． Fees for promotional materials□Yes(e．g. manuscript fee)□No

(500,000 yen or more)

6． Research funding□Yes(1,000,000yen or more)□No

7． Subsidies or Donations (1,000,000yen or□Yes

more annual payment to departments□No(department, field, or laboratory) who sharesubsidies or donations from the same commercial
entity)8． Endowed departments by commercial□Yes

entities (If any of the authors belongs to an□No

endowed department sponsored by any
commercial entity)
9． Others (e.g. trips，travel，or gifts， which□Yes

are not related to research) (50,000 yen or more)□No* 1000 yen was equivalent to 8.4 US$ or 7.7 Euro on April, 2015．
Please refer to the current currency exchange rate for Japanese yen at:
http://www.x-rates.com/d/JPY/table.html
Corresponding author’s signature:
Date of Completion:

All of the forms from each author need to be uploaded online or sent to the editorial office， and submitted withthe revised manuscript at the time of submission by the corresponding author．