Japanese Society of Physical Therapy

Japanese Society of Physical Therapy

Editorial Committee

/ / (DD/MM/YYYY)

Academic Journal “Physical Therapy Research (PTR)”

Declaration Form for Conflict of Interest

Each author of the research article should individually submit their declaration form.

Any conflict of interest with companies, organizations, or associations that may be related to the contents of the article within the past 1 year of submission of the article should be described.

1. Information of the submitted article

Title of the article:

Name of the person who submitted the article

(handwritten signature) :

Affiliations:

2. Disclosure of conflict of interest

Answer all the relevant questions given below based on the “Guidelines for disclosure of conflict of interest (COI)”

Amount / Is it applicable to you? / If applicable, write names of the organizations, etc.
1. Executives and executive advisors / 1,000,000 yen or more / Yes ・ No
2. Shareholders / 1,000,000 yen or more/5% or more / Yes ・ No
3. Patent license fees / 500,000 yen or more / Yes ・ No
4. Daily allowances (Lecture fees, etc.) / 500,000 yen or more / Yes ・ No
5. Manuscript Fee / 500,000 yen or more / Yes ・ No
6. Research fund / 2,000,000 yen or more / Yes ・ No
7.Research donation / 2,000,000 yen or more / Yes ・ No
8.Endowed laboratory / If you belong to a endowed laboratory / Yes ・ No
9. Other fees / 50,000 yen or more / Yes ・ No

*Information regarding the disclosure of conflict of interest should be listed at the end of the main text (before References) under the title “Conflicts of interest.”

*If any author has any conflict of interest, list the author’s name and the conflict of interest.

If the authors have no conflict of interest to declare, please include the following line: “There is no conflict of interest to disclose.