ADMSEP

Welcome to the ADMSEP 2012 Presenters Application

See the Call for Submissions Letter if you have not already then return here to complete the application below.

Directions: This application page has 4 components: Contact information, Abstract, Biosketch and Disclosure Statement; all are important for various reasons, including CME accreditation status. Please note that all persons involved in a presentation must complete the contact information and disclosure. However, where you lie in the authorship order determines what other components you must complete. Thus, based on the table below, please complete those that apply to you:

What application components must I complete?

	Plenary	Workshop	Poster
1st Author	a, b, c, d	a, b, c, d	a, b, c, d
2nd, 3rd, 4th, etc. Authors	b, c, d	c, d	c, d

Key: a= abstract, b= biosketch, c=contact info, d= disclosure

All applications must be submitted electronically (mailed and faxed versions will be returned). You may wish to anticipate allowing sufficient time to complete all parts of the application below, as one cannot save a draft for later revision. You may take as long as you like (this form should not "time out"), however you cannot do part of the form, navigate away from this web site or log off your pc, and return later to complete the form. Doing so will result in a blank form on return, and loss of information entered. Unless otherwise noted, all fields below are required.

Just after you click submit, you will see a confirmation page which displays the information you transmitted. If you see that you made a mistake you wish to correct at that point, you may click the "back" button on your browser, make the correction, and submit again (it will be clear from the timestamp which submission is your final version).

If you have more than one presentation for the meeting, please submit each separately (however, we only need one biosketch and disclosure on file per person, so you do not have to reenter this information more than once). Similarly, if you are submitting a revision, just complete the contact and abstract section, skipping the others. In all instances of form submission, even if it is just the disclosure statement, always enter at least your name in the "contact information" section! Questions?

Contact information

Last Name

First Name

Title (MD, PhD, Ed.D. etc)

Institution Name:

Street Address

Address (cont)

Phone (e.g.. 223-446-5000)

Fax (e.g.. 223-446-5000)

Email

City/Province

State

Zip

In this presentation, in the authorship order, I am ___ author
If you are not the first author, who is? Last Name

Need help?

Abstract
This is for first authors only (if this is not you, skip to next section). Please note that submissions containing actual data, even if preliminary or anticipated, are preferred. Please be sure to read the directions below, esp regarding abstract format choices, before entering your abstract body.
What kind of presentation are you submitting?

Plenary Workshop Poster

This is the: first time I have submitted this abstract    a revision

If you are first author, please list the other persons involved in this project:, in descending author order:

Last Name First Name Degree Institution Email Phone

Abstract Title:

Please provide your abstract body (including its educational objectives) in the box below.

-Be sure to view and use one of the required abstract format choices when composing your submission.
-Word count ≤ 350 (includes Title, Authors, Body, Objectives).
-You may wish to consider composing your abstract in a word processing program first, e.g. Microsoft Word, save it on your local pc (as a safeguard), copy it and paste it in the box below. Additionally, MS Word provides spell check, grammar check, and word count, unlike direct entry below.
-If you have additional submission materials that are not text based, e.g. a picture (.jpg), embedded graph ,or you have some critical formatting requirements, they will not be retained in the text-only box below. If this is the case, please email these items separately (as attachments to the email).
-Note that the objectives should describe the abilities or attitudes (learning outcomes) that complete the sentence, “At the conclusion of this presentation, the participant should be able to (e.g., demonstrate, recognize, diagnose, treat, etc.).” Be as specific as possible. Don’t say what you are going to teach, say what you want participants to learn.
-We strongly recommend including at least 1-2 references.

Additional information you think is relevant (optional):

If applicable, please list any anticipated AV needs below. Please note that a laptop and LCD projector will be present for all plenary sessions. However, due to cost prohibitions, ADMSEP cannot provide laptops for non-plenary presentations.

Biosketch

See directions as to whether this applies to you or not. Please provide a brief biosketch (abbreviated CV) below. An exhaustive CV is not necessary. If you wish, you may write it in another program, e.g. MS Word, save it on your local pc (as a safeguard), copy and paste it below. If your biosketch has non-text based material, e.g. embedded table, or you have some critical formatting requirements, they will not be retained in the text only box below. If this is the case, please email these items separately (as attachments to the email).

Need help?

Disclosure Statement>
(all persons in every presentation must complete)

DISCLOSURE AND CONFLICT-OF-INTEREST REVIEW FOR SPEAKERS AND AUTHORS

The current regulations of the Accreditation Council for Continuing Medical Education (ACCME) require that, in addition to the usual disclosures, an assessment (and if necessary, resolution) of the potential for a conflict-of-interest is made in advance of a CME activity certified for Category 1 credit. If a conflict-of-interest is identified, resolution of the conflict-of- interest must also be made in advance of announcements and advertising for the CME activity. To fulfill these requirements, the CME-sponsoring institution requests that you complete and submit the following questionnaire as soon as possible to the Office of Clinical Affairs, Chicago Medical School, 3333 Green Bay Road, North Chicago, IL 60064. The presentations of speakers and authors who decline to submit the requested information are not eligible for certification for Category 1 CME credit.

USE OF GENERIC NAMES:   To avoid commercial bias, or any appearance of commercial bias, speakers and authors should use generic names for medications and other commercial products. When it is important to use a proprietary (trade) name, concurrent mention of the proprietary names of several equivalent products may help avoid the appearance of bias.

INVESTIGATIONAL PRODUCTS AND “OFF-LABEL” USES OF PRODUCTS: If the speaker or author mentions the use of medications, devices or other products for purposes for which they have not been approved (“off-label”), or products approved only for investigational use, the speaker must clearly indicate that these uses of the product are not approved or are investigational.

PLEASE CHECK OFF ALL RELEVANT BOXES

Note that reasonable honoraria, support for travel, lodging or meals, and positive responses to one or more of the other questions do not necessarily indicate a conflict-of-interest.

1. I (will)   (will not)    be receiving an honorarium for this CME activity.

2. I (will)   (will not)   be receiving support for travel and/or lodging and/or meals for this CME activity.

3. No, I have not had within the past 12 months a financial or other significant relationship with a commercial organization that markets a product to which I will refer as speaker or author.

4. Yes, I* have had within the past 12 months a financial or other significant relationship with a commercial organization that markets a product to which I will refer as speaker or author. [Check where appropriate below and insert name of the manufacturer(s) of the product(s) to which you will refer. Please also answer questions below]:

a (I am) (had been) a recipient of monetary or other significant research support from:

b (I am) (had been) a paid consultant for:

c (I am) (had been) a
(full) (part time) employee of:

d (I am) (had been) listed on a speakers’ list for:

e (I am) (had been)
(paid) (unpaid) a member of an advisory or similar board for:

f (I am) had been a member of the Board of Trustees of:

g Other type of relationship [please describe and note if current or within the past 12 months]:

h The product to which I will refer will be identified:
Only by its generic name
By its proprietary (trade) name but with the concurrent mention of the proprietary names of similar products of other manufacturers
By its proprietary (trade) name, without concurrent mention of similar competitor products
By its proprietary (trade) name [there are no similar competitor products]

5. I have had within the past 12 months a financial or other significant relationship with a commercial organization that markets a product to which I will refer as speaker or author, BUT I will not be recommending any of their products over similar competitor products.

6. I have had within the past 12 months a financial or other significant relationship with a commercial organization that markets a product to which I will refer as speaker or author, AND I will be recommending one or more of their products over similar competitor products. The recommendation will be based [check one]:

a Exclusively on data and/or clinical experience not generated by the manufacturer or derived from manufacturer-sponsored studies.

b The recommendation will be based on data and/or clinical experience most of which were not generated by the manufacturer or derived from manufacturer-sponsored studies.

c The recommendation will be based on data and/or clinical experience, most of which were generated by the manufacturer or derived from manufacturer-sponsored studies

d The recommendation will be based exclusively on data and/or clinical experience generated by the manufacturer or derived from manufacturer-sponsored studies.

By checking this box I affirm that I have read the above information, understand it and have accurately responded as submitted.

Title(s) of my presentation(s):

Contact info (ESSENTIAL and please also include your name in the "contact information" section at the top of this form!) :

Last Name   Middle Initial

First Name Email

Date of the Activity Phone

*Includes financial or other significant relationships of the speaker’s/author’s spouse.

Optional: Special note I wish to make at this time:

Important:
-Please do not click "submit" until you have completed the application in full.
-In all instances of form submission, even if it is just the disclosure statement, always include your name in the "contact information" section at the top of the form!
-After clicking submit, you should see a web page which notes your responses; at this point you are done.
-However, if you see that you made a mistake at the confirmation page, simply click the "back" button on your browser, make the correction(s), and click submit again (it will be clear from the timestamp which submission is your final version). You do not have to reenter all the info just to correct a mistake as the form "remembers" what you put in previously.

Questions/Help?
-About the application process: john.spollen@va.gov [(pager) 501-688-6679].
-About disclosures:   Ms Elsa Kurien, Director for CME & GME Office of Clinical Affairs, Chicago Medical School at Rosalind Franklin University of Medicine and Science [elsa.kurien@rosalindfranklin.edu; 847-578-3341 (Office), 847-578-3341 (Fax) 847-578-3320]
-If you have a question about the form itself, please contact webmaster.

-Please note that all relevant components must completed by all presentation participants by the deadline noted elsewhere

r. 11/21/11

Last Name
First Name
Title (MD, PhD, Ed.D. etc)
Institution Name:
Street Address
Address (cont)
Phone (e.g.. 223-446-5000)
Fax (e.g.. 223-446-5000)
Email
City/Province
State
Zip

1.	I (will) (will not) be receiving an honorarium for this CME activity.
2.	I (will) (will not) be receiving support for travel and/or lodging and/or meals for this CME activity.


3.	No, I have not had within the past 12 months a financial or other significant relationship with a commercial organization that markets a product to which I will refer as speaker or author.
4.	Yes, I* have had within the past 12 months a *financial or other significant relationship* with a commercial organization that markets a product *to which I will refer* as speaker or author. [Check where appropriate below and insert name of the manufacturer(s) of the product(s) to which you will refer. Please also answer questions below]:


a	(I am) (had been) a recipient of monetary or other significant research support from:
b	(I am) (had been) a paid consultant for:
c	(I am) (had been) a (full) (part time) employee of:
d	(I am) (had been) listed on a speakers’ list for:
e	(I am) (had been) (paid) (unpaid) a member of an advisory or similar board for:
f	(I am) had been a member of the Board of Trustees of:
g	Other type of relationship [please describe and note if current or within the past 12 months]:
h	The product to which I will refer will be identified: Only by its generic name By its proprietary (trade) name but with the concurrent mention of the proprietary names of similar products of other manufacturers By its proprietary (trade) name, without concurrent mention of similar competitor products By its proprietary (trade) name [there are no similar competitor products]


5.		I have had within the past 12 months a financial or other significant relationship with a commercial organization that markets a product to which I will refer as speaker or author, BUT I will not be recommending any of their products over similar competitor products.

6.	I have had within the past 12 months a financial or other significant relationship with a commercial organization that markets a product to which I will refer as speaker or author, AND I will be recommending one or more of their products over similar competitor products. The recommendation will be based [check one]:
	a	Exclusively on data and/or clinical experience not generated by the manufacturer or derived from manufacturer-sponsored studies.
	b	The recommendation will be based on data and/or clinical experience most of which were not generated by the manufacturer or derived from manufacturer-sponsored studies.
	c	The recommendation will be based on data and/or clinical experience, most of which were generated by the manufacturer or derived from manufacturer-sponsored studies
	d	The recommendation will be based exclusively on data and/or clinical experience generated by the manufacturer or derived from manufacturer-sponsored studies.

Last Name	Middle Initial
First Name	Email
Date of the Activity	Phone