Midwest Surgical Association

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Annual Meeting: Online Abstract Submission Form

ABSTRACT DEADLINE: Friday, March 2, 2012 - 11:59pm CST

INSTRUCTIONS

Please read instructions carefully.
Human Subjects: Studies involving human subjects must be certified by choosing "yes" in designated space on form.
Format: The abstract body should be informative and concise and must include the following:
1. OBJECTIVE: Sentence stating the specific objective (unless stated in the title)
2. METHODS: Brief statement of methods
3. RESULTS: Summary of results
4. CONCLUSION: Statement of conclusion
The abstract body (not counting abstract title or author string) must not exceed 250 words.
Deadline: Abstracts must be submitted online by Friday, March 2, 2012. NO abstract will be accepted after the deadline.
Abstract Category: Please indicate on the form if the abstract is to be entered in the Resident Competition or New Member Competition, or if it is for the Spectacular Problems in Surgery session. (Note: New members are those elected at the previous annual meeting.)
Presentation: On submission, please indicate if the abstract is to be considered for oral presentation, poster presentation, or no preference.
Attendance: Member sponsors of non-member papers must be present at the meeting.
Restrictions: Graphs, photos and tables are not accepted.
Questions: Please direct all questions to the MSA Headquarters office at 913-402-7102 or info@midwestsurg.org

* indicates required fields.

Principal Author Information (Receives correspondence.)

*Name

First:
Middle:
Last:
Credentials:

Institution

*Address (Line 1)

Address (Line 2)

*City

*State

*Zip Code

*Phone

*Fax

*Email

Presenter Information

*Name

First:
Middle:
Last:
Credentials:

Institution

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Phone

Fax

*Email

Sponsoring Institution Information

If none of the authors are MSA members, please add name and address of sponsoring member.

First:
Middle:
Last:
Credentials:

*Email

*Institution Name

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Additional Information
*Presentation Category
*This is to certify that the information contained in this abstract represents original work that has not been previously published and will not be presented at a national or international meeting prior to the dates of this meeting.
*I certify that informed consent was obtained and, where indicated, approval received by the IRB or Committees on Human Experimentation.
ALL AUTHORS: Principal Author, Presenter, and Co-Author(s): Please include last name and initials for each-author (ie, Smith KM, Johnson CA)*
Abstract Competition
*Title of Abstract NOTE: PLEASE USE ALL CAPITAL LETTERS WHEN LISTING ABSTRACT TITLE. Do NOT use abbreviations or references to authors or institutions. Watch for spelling! How the title is presented here is how it will be printed in meeting materials. (Sample Title: THIS IS THE TITLE OF OUR ABSTRACT)
Abstract (limited to 250 words, not counting abstract title or author string)* Please do not include tables, graphs, charts or photos Spectacular Problems in Surgery Abstract (limited to 100 words) Please do not include tables, graphs, charts or photos	Number of words left:

Speaker Disclosure
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS Per ACCME regulations, the American College of Surgeons disclosure process 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 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. * Please check here as acknowledgement that you have read the terms of disclosure and will comply with these terms, should your abstract be selected for the program. Check One (Required): I do not have any relevant financial relationships with any commercial interests AS IT PERTAINS TO THIS PRESENTATION I do have the following relevant financial relationships to disclose AS IT PERTAINS TO THIS PRESENTATION:
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):
Specify your role:
Commercial Interest:
Nature of Relevant Financial Relationship:
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.

Submit Form

By checking this acceptance agreement, I (we) certify that the information contained in this presentation and the manuscript represent original work that has not been previously published, and will not have been presented or be under consideration for publication at a national or international meeting prior to the dates of this meeting. By checking this agreement, I (we) also certify that the data in this abstract have been seen and approved by the senior author, and/or sponsoring member, as appropriate.

I (We) will also submit a manuscript to the American Journal of Surgery by Monday, July 23, 2012, and we understand that acceptance of this paper for presentation does not guarantee publication in the journal. Papers will still be evaluated through a full editorial review.

Midwest Surgical Association - 5019 W. 147th Street - Leawood, Kansas 66224 - Phone: 913.402.7102