Submission Form

Abstract Deadline: Monday, August 14, 2017
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Abstract
* Surgical Category:
Bariatric
Breast
Cardiac
Colorectal
Critical Care/Trauma
Endocrine
General
Hepatobiliary
Neurology
Ob/Gyn
Ophthalmology
Orthopedic
Otolaryngology
Pediatric
Plastic/Maxillofacial
Thoracic
Urology
Vascular
* Abstract Title:
* Author Block:
Sample author block:
John Smith1, Jane Doe2
1Sample University, Beverly, MA, USA
2Sample Hospital, Beverly, MA, USA
* Abstract Body
Upload Charts & Tables:
Tables and charts are each worth 25 words and can be uploaded directly.
250 WORDS TOTAL FOR ALL 4 SECTIONS INCLUDING FIGURES AND TABLES
 
Abstract Presenter
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  Middle Initial:
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* Degree:
* Institution:
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  I am an MCACS member

If you are not an MCACS member, please enter the name of one of your co-authors who is, or an MCACS member who is sponsoring the abstract:

 
Presenting Author Disclosure Information:
 
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.
 
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 MCACS 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.


 
 
Massachusetts Chapter of the American College of Surgeons
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Phone: 978-927-8330 | Fax: 978-524-0498