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1、(FormNo.3)ConflictofInterestReportforExecutives,CommitteeChairpersons,andMembersoftheMedicalEthicsCommittee(Proposal)(Calculationperiod:Apr.1,20XX〜Mar.31,20XX)(Officeuseonly)ReceptionNo.Receptiondate-YearMonthDayTotheChairmanoftheBoardofDirectorsoftheJapaneseSoc
2、ietyofPathology:Nameofthepersonsubmittingthereport:Nameofthefacilityconcerned(organization,departmentorclinic):Nameoftheexecutiveposition:CommitteenameattheSociety:MemberoftheCommitteeA.Itemsconcerningthereporterhimself/herself1.Haveyoureceivedanyremunerationasa
3、nexecutiveoradvisorfromanenterpriseorprofit-makingorganization?Ifyes,enterthesumreceived.(Entryrequirediftheyearlysumreceivedfromoneenterpriseororganizationexceeds1millionyen)YesorNo(circletheapplicableanswer)(IfYes,filloutthecontentbelowforeachenterpriseororgan
4、ization)Nameoftheenterpriseororganization:Position(Executive,advisor,etc.):Amountofremuneration:2.Doyouownanystocksorhaveyoureceivedanyearningsfromstocks?(Entryrequirediftheyearlyearningsreceivedfromoneenterpriseexceed1millionyen,orifthestockholdingsexceed5%ofth
5、etotalstock)?YesorNo(circletheapplicableanswer)(IfYes,filloutthecontentbelowforeachenterpriseororganization)Nameoftheenterpriseororganization:Numberofstocksowned:Stockvalueatthetimeofthereport(perstock):Eamingsfromthestockforthepreviousyear:3.Haveyoureceivedanyr
6、emunerationasroyaltyfeesfromanenterpriseorprofit-makingorganization?(Entryrequirediftheyearlyroyaltyfeesreceivedfromoneenterpriseexceed1millionyen)YesorNo(circletheapplicableanswer)(IfYes,filloutthecontentbelowforeachpatent)Nameoftheenterpriseororganization:Pate
7、ntname:Royaltyfee:4.Haveyoureceivedanydailyallowance(lecturefees,etc.)asremunerationforthetimeoreffortinvolvedinattendingameeting(presentation)fromanenterpriseorprofit-makingorganization?Ifyes,enterthesumreceived・(EntryrequirediftheyearlysumofthelecturefeesYesor
8、No(circletheapplicableanswer)(IfYes,filloutthecontentbelowforeachenterpriseororganizationprovidingthefunds)Nameoftheenterpriseororganization:Lecturefee,etc.:receivedf
