Abstract Submission

* - required field
Submission
* Submission Type: Late-Breaking Abstract
Please consider this abstract for the Resident Paper Award
* Title:
* Summary:
  250 or less for abstract and 100 or less for a video. Using words.
* Author Block:
Individual(s)
Institution(s)
Sample author block
Individual(s) Ethan Kung1, Allessandro Giardini2, T-Y Hsia2, Alison Marsden1, MOCHA Investigators2
Institution(s) 1UCSD, La Jolla, CA; 2Great Ormond Street Hospital for Children, London, United Kingdom
Optional attachments
(ex: tables or images)
1.
2.
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4.
5.

Presenter
* First Name:
Middle Initial:
* Last Name:
Suffix:
* Degree:
* Institution:
* Address:
* City:
State:
* Zip:
* Country:
* Phone:
Fax:
* Email:
* I am a member of CHSS: Yes No
If you are not a member of CHSS, please enter the name of your member sponsor:
Member Name

 
 
In accordance with ACCME regulations, the American College of Surgeons, as the accredited provider of this activity, must ensure that anyone who is in a position to control the content of the education activity has disclosed to us all relevant financial relationships with any commercial interest (see below for definitions) as it pertains to the content of the presentation. Should it be determined that a conflict of interest exists as a result of a financial relationship you may have, you will be contacted and methods to resolve the conflict will be discussed with you. In addition, all affirmative disclosures must be revealed by a slide at the beginning of the presentation. Failure or refusal to disclose or the inability to resolve the identified conflict will result in the withdrawal of the invitation to participate.
  • List the names of proprietary entities producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.
  • Explain what you or your spouse/partner received (ex: salary, honorarium etc) and specify your role.
If your presentation describes the use of a device, product, or drug that is not FDA approved or the off-label use of an approved device, product, or drug or unapproved usage, it is your responsibility to disclose this information verbally to the learner during your presentation.
 
Please complete a disclosure below for each of the authors listed
Author 1:
* Full Name
This author does not have any relevant financial relationships with commercial interests that pertain to the content of his/her presentation
 
This author does have relevant financial relationships with commercial interests that pertain to the content of his/her presentation
Commercial Interest Nature of Relevant Financial Relationship
(Include all those that apply)
What I or spouse/partner received My role
Example: Company X Honorarium Speaker
Please email April Abenilla with your full disclosure statement if you have more than 5 disclosures to report.

What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest, (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. My Role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities.
 
Author 2:
* Full Name
This author does not have any relevant financial relationships with commercial interests that pertain to the content of his/her presentation
 
This author does have relevant financial relationships with commercial interests that pertain to the content of his/her presentation
Commercial Interest Nature of Relevant Financial Relationship
(Include all those that apply)
What I or spouse/partner received My role
Example: Company X Honorarium Speaker
Please email April Abenilla with your full disclosure statement if you have more than 5 disclosures to report.

What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest, (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. My Role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities.
 
 

 
 
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