Symposia Title: 
First Author's Name: First Author's Email: 
First Author's Daytime Phone Number: 

Symposia Overview
Describe the theme and purpose of the symposium.

Learner Objectives
Learner objectives should be measurable outcomes of the presentation.

#1
#2

Abstracts
Abstracts must be no longer than 300 words. If accepted, the presenter agrees to have the submitted abstract published in conference documentation. No author information should be presented in this space.

Abstract #1

Title:

Please type or paste your abstract. The field will expand as you type or paste your text.

Abstract #2

Title:

Please type or paste your abstract. The field will expand as you type or paste your text.

Abstract #3

Title:

Please type or paste your abstract. The field will expand as you type or paste your text.

Audiovisual Needs
Please mark the type of audiovisual equipment requested for your paper presentation.

Overhead projector 
Slide projector 
LCD projector for computer presentation 
Laptop computer 
Other 

Author Profiles:

Author Profile #1
 

Name:

Degrees:

Home Address

Number and Street:

City, State, & Zip:

Business Address

Employer Name/Department:

Number and Street:

City, State, & Zip:

Telephone

Business:

Home:

Email:

List Degree, Date earned, Institution name, Address, and Major area of study.

1..

2..

3..

4..

Present Position (title and description):

Professional experience or areas of expertise (including publications) which contribute to your involvement with this project or research being submitted for review.

Conflict of Interest Statement

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity and any potential conflict must be resolved. In order to ensure balance, independence, objectivity and scientific rigor at all programs, the planners and faculty must make full disclosure indicating whether the planner, faculty or content specialist and/or his/her spouse family has any relationships with pharmaceutical companies, biomedical device manufacturers and/or corporations whose products or services are related to pertinent therapeutic areas. All planners, faculty, content specialists and feedback specialists participating in CE activities must disclose to the audience information listed below.

A. Is there a potential conflict of interest? Yes No

If yes, list company(ies) with relationship:
Relationship Name of Commercial Company(ies):
Research Support:
Speakers’ Bureau:
Consultant:
Shareholder:
Large Gift(s):
Other Support:

B. Discussion of unlabeled uses: Yes No
If yes, you must disclose this information during your presentation. How will you do this?
Verbal statement during the presentation
Information provided on handouts
Information provided in audiovisuals (slides, overhead, powerpoint, etc.)
Other: Describe:

C. How will any conflict of interest be resolved?
Have discussed this conflict with individual who is now aware of and agrees to our policy.
Presenter has signed a statement that says s/he will present information fairly and without bias.
The session will be monitored to ensure conflict does not arise.
Not applicable since no conflict of interest.
Other: Describe:

All information disclosed must be shared with the audience either on the program handouts, advertising and/or audiovisual presentation.

Date:
By checking this box, I am providing my electronic signature approving all the information entered above.

Author Profile #2
 

Name:

Degrees:

Home Address

Number and Street:

City, State, & Zip:

Business Address

Employer Name/Department:

Number and Street:

City, State, & Zip:

Telephone

Business:

Home:

Email:

List Degree, Date earned, Institution name, Address, and Major area of study.

1..

2..

3..

4..

Present Position (title and description):

Professional experience or areas of expertise (including publications) which contribute to your involvement with this project or research being submitted for review.

Conflict of Interest Statement

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity and any potential conflict must be resolved. In order to ensure balance, independence, objectivity and scientific rigor at all programs, the planners and faculty must make full disclosure indicating whether the planner, faculty or content specialist and/or his/her spouse family has any relationships with pharmaceutical companies, biomedical device manufacturers and/or corporations whose products or services are related to pertinent therapeutic areas. All planners, faculty, content specialists and feedback specialists participating in CE activities must disclose to the audience information listed below.

A. Is there a potential conflict of interest? Yes No

If yes, list company(ies) with relationship:
Relationship Name of Commercial Company(ies):
Research Support:
Speakers’ Bureau:
Consultant:
Shareholder:
Large Gift(s):
Other Support:

B. Discussion of unlabeled uses: Yes No
If yes, you must disclose this information during your presentation. How will you do this?
Verbal statement during the presentation
Information provided on handouts
Information provided in audiovisuals (slides, overhead, powerpoint, etc.)
Other: Describe:

C. How will any conflict of interest be resolved?
Have discussed this conflict with individual who is now aware of and agrees to our policy.
Presenter has signed a statement that says s/he will present information fairly and without bias.
The session will be monitored to ensure conflict does not arise.
Not applicable since no conflict of interest.
Other: Describe:

All information disclosed must be shared with the audience either on the program handouts, advertising and/or audiovisual presentation.

Date:
By checking this box, I am providing my electronic signature approving all the information entered above.

Author Profile #3
 

Name:

Degrees:

Home Address

Number and Street:

City, State, & Zip:

Business Address

Employer Name/Department:

Number and Street:

City, State, & Zip:

Telephone

Business:

Home:

Email:

List Degree, Date earned, Institution name, Address, and Major area of study.

1..

2..

3..

4..

Present Position (title and description):

Professional experience or areas of expertise (including publications) which contribute to your involvement with this project or research being submitted for review.

Conflict of Interest Statement

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity and any potential conflict must be resolved. In order to ensure balance, independence, objectivity and scientific rigor at all programs, the planners and faculty must make full disclosure indicating whether the planner, faculty or content specialist and/or his/her spouse family has any relationships with pharmaceutical companies, biomedical device manufacturers and/or corporations whose products or services are related to pertinent therapeutic areas. All planners, faculty, content specialists and feedback specialists participating in CE activities must disclose to the audience information listed below.

A. Is there a potential conflict of interest? Yes No

If yes, list company(ies) with relationship:
Relationship Name of Commercial Company(ies):
Research Support:
Speakers’ Bureau:
Consultant:
Shareholder:
Large Gift(s):
Other Support:

B. Discussion of unlabeled uses: Yes No
If yes, you must disclose this information during your presentation. How will you do this?
Verbal statement during the presentation
Information provided on handouts
Information provided in audiovisuals (slides, overhead, powerpoint, etc.)
Other: Describe:

C. How will any conflict of interest be resolved?
Have discussed this conflict with individual who is now aware of and agrees to our policy.
Presenter has signed a statement that says s/he will present information fairly and without bias.
The session will be monitored to ensure conflict does not arise.
Not applicable since no conflict of interest.
Other: Describe:

All information disclosed must be shared with the audience either on the program handouts, advertising and/or audiovisual presentation.

Date:
By checking this box, I am providing my electronic signature approving all the information entered above.

If you have another Author Profile to enter please continue;
or click here to access the SUBMIT button

Author Profile #4
 

Name:

Degrees:

Home Address

Number and Street:

City, State, & Zip:

Business Address

Employer Name/Department:

Number and Street:

City, State, & Zip:

Telephone

Business:

Home:

Email:

List Degree, Date earned, Institution name, Address, and Major area of study.

1..

2..

3..

4..

Present Position (title and description):

Professional experience or areas of expertise (including publications) which contribute to your involvement with this project or research being submitted for review.

Conflict of Interest Statement

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity and any potential conflict must be resolved. In order to ensure balance, independence, objectivity and scientific rigor at all programs, the planners and faculty must make full disclosure indicating whether the planner, faculty or content specialist and/or his/her spouse family has any relationships with pharmaceutical companies, biomedical device manufacturers and/or corporations whose products or services are related to pertinent therapeutic areas. All planners, faculty, content specialists and feedback specialists participating in CE activities must disclose to the audience information listed below.

A. Is there a potential conflict of interest? Yes No

If yes, list company(ies) with relationship:
Relationship Name of Commercial Company(ies):
Research Support:
Speakers’ Bureau:
Consultant:
Shareholder:
Large Gift(s):
Other Support:

B. Discussion of unlabeled uses: Yes No
If yes, you must disclose this information during your presentation. How will you do this?
Verbal statement during the presentation
Information provided on handouts
Information provided in audiovisuals (slides, overhead, powerpoint, etc.)
Other: Describe:

C. How will any conflict of interest be resolved?
Have discussed this conflict with individual who is now aware of and agrees to our policy.
Presenter has signed a statement that says s/he will present information fairly and without bias.
The session will be monitored to ensure conflict does not arise.
Not applicable since no conflict of interest.
Other: Describe:

All information disclosed must be shared with the audience either on the program handouts, advertising and/or audiovisual presentation.

Date:
By checking this box, I am providing my electronic signature approving all the information entered above.

Author Profile #5
 

Name:

Degrees:

Home Address

Number and Street:

City, State, & Zip:

Business Address

Employer Name/Department:

Number and Street:

City, State, & Zip:

Telephone

Business:

Home:

Email:

List Degree, Date earned, Institution name, Address, and Major area of study.

1..

2..

3..

4..

Present Position (title and description):

Professional experience or areas of expertise (including publications) which contribute to your involvement with this project or research being submitted for review.

Conflict of Interest Statement

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity and any potential conflict must be resolved. In order to ensure balance, independence, objectivity and scientific rigor at all programs, the planners and faculty must make full disclosure indicating whether the planner, faculty or content specialist and/or his/her spouse family has any relationships with pharmaceutical companies, biomedical device manufacturers and/or corporations whose products or services are related to pertinent therapeutic areas. All planners, faculty, content specialists and feedback specialists participating in CE activities must disclose to the audience information listed below.

A. Is there a potential conflict of interest? Yes No

If yes, list company(ies) with relationship:
Relationship Name of Commercial Company(ies):
Research Support:
Speakers’ Bureau:
Consultant:
Shareholder:
Large Gift(s):
Other Support:

B. Discussion of unlabeled uses: Yes No
If yes, you must disclose this information during your presentation. How will you do this?
Verbal statement during the presentation
Information provided on handouts
Information provided in audiovisuals (slides, overhead, powerpoint, etc.)
Other: Describe:

C. How will any conflict of interest be resolved?
Have discussed this conflict with individual who is now aware of and agrees to our policy.
Presenter has signed a statement that says s/he will present information fairly and without bias.
The session will be monitored to ensure conflict does not arise.
Not applicable since no conflict of interest.
Other: Describe:

All information disclosed must be shared with the audience either on the program handouts, advertising and/or audiovisual presentation.

Date:
By checking this box, I am providing my electronic signature approving all the information entered above.