LAACS Abstract Form

* Abstract Title:

* Authors

(List Principle Author first):

* Institution Name:

* Address:

* City:

* State:

* Zip:

* Presenter

* Presenter Email:

* Presenter Phone:

Presenter Fax:

Presenter Cell:

* Office Contact:

* Office Email:

* Office Phone:

* Office Email:

* Initial Here:

* Resident Competition:

Yes

No

*

Abstract Type:

Surgical Oncology

Breast/Endocrine

Cardiovascular/Thoracic

Gastro Intestinal Tract

Trauma/Critical Care

Other

* Please provide a short

bio for the person

presenting this abstract:

* Upload Your Abstract
File:

Speaker Disclosure

Disclosure of Relevant Financial Relationships:

In order to comply with the ACCME’s Updated Standards for Commercial Support, LAACS, as the accredited CME provider of this activity, has implemented a new disclosure process to 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. The goal of this process is not to exclude people who have conflicts, but to manage these conflicts while benefiting from your expertise. 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 manage 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 information may result in the withdrawal of the invite to participate.

* Terms:

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:

I do not have any relevant financial relationships with any commercial interests as it pertains to this presentation.

I have the following disclosures to report:

Disclosures to Report:

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.

Explian what you or
your spouse/partner
received (ex:salary,

honorarium, etc):

* Specify your role:

* Comercial Interest:

* Nature of Relevant
Financial Relationship:

Attention:

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.

* Indicates Response Required