Form 1

COI Declaration for Manuscripts Submitted to the Toho Journal of Medicine(All answers should pertain to the period one year before the submission date)

Declarant’s Name

Affiliation

Position

Title of Submitted Manuscript

In the event that the manuscript itself does not describe author Conflict of Interest (COI), please
describe, in all sections below, any companies or organizations you deal with or have dealt with, inorder to ensure complete disclosure of any COI relevant to the submitted manuscript. In
manuscripts with multiple authors, a separate COI Declaration form must be submitted by eachauthor. (All questions below pertain to the period one year before the date of manuscript
submission.)
Question Relevant
1. Do you work for, or act as an advisor to, a company or
for-profit organization (FPO)?
(Provide details if you receive 1 million yen/year or
more from the company or organization)

Corresponding
Situation(You)
Yes / No(Your familymember)*Yes / No

2. Do you own stocks or shares?

(You)(Provide details if you receive 1 million yen/year or more

Yes / Noin stock-related income from any one company, or if you(Your familyown 5% or more of any company’s stocks or shares)

member)*Yes / No

3. Do you receive income from any company or FPO for the(You)use of intellectual property to which you hold the rights?

Yes / No

(Provide details if you receive 1 million yen/year or more(Your familyfrom such sources)

member)*Yes / No

4. Do you receive, or have you received, payments for
lectures given to any company or FPO, or incompensation for your time spent attending meetings ormaking presentations for them?
(Provide details if you have received a total of 500,000
yen/year or more from any one company or FPO)(You)
Yes / No

Details ofCompanies,

5. Have you received payment(s) for writing, or having yourname used, in any pamphlet or publicity material of any
company or FPO?
(Provide details if you have received a total of 500,000(You)
Yes / Noyen/year or more from any one company or FPO)
6. Have you received payments or research funds forcontract research for, or joint research with, andcompany or FPO?
(Provide details if you have received a total of(You)Yes / No

1 million yen/year or more from any company or FPO)
7. Have you received scholarships or other donations fromany company or FPO?

(You)
Yes / No

(Provide details if you have received a total of
1 million yen/year or more from any company or FPO)
8. Are any of your courses financially supported by donations
from any company or FPO?
(Provide details of any course with which you are involvedthat is receiving such funding)(You)
Yes / No

9. Have you received any gifts, or allowances for travel
unrelated to your research, from any company or FPO?
(Provide details if you have received a total of 50,000
yen/year in gifts or travel allowances or more from any(You)Yes / Nocompany or FPO)*“Family members” refers to your spouse and any members of your immediate family.
(This form will be kept on file for two years, after which it will be destroyed. It will not be shown
without sufficient reason to anyone but members of the Editorial Committee of the Toho Journalof Medicine.)

Date:

Signature: