College of Medicine and CMU Health Research Symposium, April 11, 2018 Abstract Submission

Please complete this form and submit electronically to: cmedresearch@cmich.edu

I. General Information

Name:

Select a trainee level:

Abstract Title:

II. Author Information

Enter the authors in the order you wish them to appear.

1. First Author

Name:

Email Address:

Department/Residency Program/College:

2. Second Author

Name:

Email Address:

Department/Residency Program/College:

3. Third Author

Name:

Email Address:

Department/Residency Program/College:

4. Fourth Author

Name:

Email Address:

Department/Residency Program/College:

5. Fifth Author

Name:

Email Address:

Department/Residency Program/College:

*If you have additional authors, Please add an additional page to your application.

III. Advisor/Presenter Information

Name of Advisor: Email Address: Department/Residency Program/College:

Name of Presenter: Email Address: Department/Residency Program/College:

*If you are the presenter, your attendance and participation at the Symposium is required.

IV. Abstract Content

Abstracts should be completed on one page, single spaced, maximum of 500 words (not to include authors, title and department and institution affiliations), with a minimum font size of 11. Attach as a Word document or as a PDF to the application email. Include the clearly labeled sections.

1. Abstract Title2. Authors. Please underline Presenter.3. Department/Institutional Affiliation4. Background5. Methods6. Results7. Conclusions8. Significance

V. IACUC/IRB Approval Obtained

VI. Research Category

Designate one specific research category from the list below.

VII. Presentation Category

A limited number of oral presentations will be selected due to time constraints. Please indicate if you would like your abstract to be considered for an oral and/or poster presentation, or if you wish your abstract to be considered for a poster only presentation.

If you have additional reasons for an oral or poster preference, please advise below. This does not mean you will receive an oral presentation.

VIII. Conflict of interest

*Please complete the disclosure form below and return with this application.

Page 1 of 2 CM CME Disclosure

Disclosure of Relevant Financial Relationships

CMU College of Medicine Office of Continuing Medical Education (CM CME) is accredited by the Michigan State Medical Society to provide continuing medical education (CME) to physicians. CM

CME adheres to and adopts the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support and requires everyone in a position to control the content of an accredited CME activity to disclose all relevant financial relationships with any commercial interest (see Glossarybelow).Name:

of Activity: Date of Activity:

First, list the names of commercial interests (defined in the “Glossary of Terms” below) with which you oryour 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.

Second, describe what you or your spouse/partner received (ex: salary, fee, research grant, etc). CMCME does NOT want to know how much you received.

Third, describe your role.

Commercial InterestNature of Relevant Financial Relationship

(Include all those that apply)What was received For What Role?

Example: Company ‘X’ Speaker Fee Promotional Speaker

I do not have any relevant financial relationships with any commercial interests.

Signature(typed name serves as signature) Date

Example terminology What was received: Salary, royalty, intellectual property rights, research grant, consulting fee, speaker fee, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.

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 (please specify).

2018 Research SymposiumApril 11, 2018

Page 2 of 2 CME Disclosure

Glossary of Terms

Commercial Interest The ACCME defines a “commercial interest” as any entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests. For more information, visit www.accme.org.

Financial relationshipsFinancial relationships are those relationships in which the individual benefits by receiving a 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. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

Relevant financial relationships ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

Conflict of Interest Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.