Conflict of Interest disclosure slide for representative speakers or investigators Research fund □scientific research fund □contract □donation □other （ ） □N/A Sponsor Name of lead presenter Institution or company/position No If yes, please specify the name of company, organization, your status. employee or adviser of company and/or profit-making organization □ profit of stock patent fee lecturer fee manuscript fee research expenses from company contributions or endowed chair fees of testimony, judgment, comment, etc. presents or other payment representative of organization for clinical study receiving research expenses from company Name of principal investigator Institution or company/position No If yes, please specify the name of company, organization, your status. employee or adviser of company and/or profit-making organization □ profit of stock patent fee lecturer fee manuscript fee research expenses from company contributions or endowed chair fees of testimony, judgment, comment, etc. presents or other payment representative of organization for clinical study receiving research expenses from company 研究責任医師氏名 所属 金額 該当の有無 該当する場合：企業名等 企業等の職員 － 有 ・ 無 企業等の顧問職 100万円以上 株 100万円以上の利益／全株式の5%以上 講演料など 50万円以上 原稿料など 寄付金 200万円以上 委受託研究 専門的助言・証言 その他