MEDICAL STUDENT POSTER SESSION

ABSTRACT SUBMISSION FORM

Submission Deadline:
Monday, July 7, 2014 (11:59 PM - Central Time)

ACS Medical Student Program
October 26-28, 2014
San Francisco, CA

Medical students attending the ACS Medical Student Program are invited to submit abstracts for basic science, clinical, or educational research projects in which they have a substantive role.

Please note that case reports will not be considered.

Selected abstracts will be presented during the
Medical Student Poster Session,
a part of the ACS Medical Student Program
on Sunday, October 26, 2014.

Poster awards will be presented on Tuesday, October 28, 2014.
(NOTE: Attendance on Tuesday is not a requirement for participation.)

Presenters will not receive any financial remuneration. Travel to the ACS Medical Student Program, lodging, and poster construction costs are the responsibility of the presenter.

Please fill out the following sections in order to submit your Abstract.

i. Abstract Information

ii. Submitter Information

iii. Co-Author Information

Fields labeled with (*) are required.
For fields labeled Degrees/Credentials:, separate degrees with a (,) comma and a space. eg: MD, PhD, FACS
For further instructions or clarification, please contact:
Nicole Laroco
Administrator, Educational Programs
Division of Education

phone: 312.202.5404
e-mail: nlaroco@facs.org

i - Abstract Information

(*)

Category:    

 

(*)

Title:   NOTE: Use proper title capitalization.     eg: " The Sky Is a Shade of Blue "

 

 

         
If you copied-and-pasted text from a word processing document, DO NOT USE non-standard characters because they may not transmit properly. Click here to view recommendations.

 
Entire Abstract body ( Introduction + Methods + Results + Conclusions ) should not exceed 300 words.

(*)

INTRODUCTION:

 

 

           

(*)

METHODS:

 

 

           

(*)

RESULTS:

 

 

           

(*)

CONCLUSIONS:

 

 

           
Entire Abstract body ( Introduction + Methods + Results + Conclusions ) should not exceed 300 words.
           Click this button to calculate TOTAL number of words     

(*)

Has this abstract already been published, presented or submitted to another program for publication ?
No     Yes

 

 

If you have selected "Yes", was the abstract submitted to a regional or national program ?
Regional     National

WHERE and WHEN has this exhibit been shown?
( eg: ACS Clinical Congress 2004 )

 

(*)

Organization where research originated or contributed:
Institution name ONLY ( no department names or misc. information )

 

 

 

(*)

City:

 

(*)

State / Prov:
If USA or Canada, use 2 letter abbreviation.

 

(*)

Country:

 

ii - Submitter Information
( must be a Medical Student )

(*)

Prefix:

 

(*)

First Name:

 

 

Middle Name or Initial(s):

 

(*)

Last Name:

 

(*)

Year in Medical School:

 

 

ONLY if you selected 'Other', please explain below:     ( otherwise leave BLANK )

         
 

 

Degrees/Credentials:

eg: MD, PhD, FACS  

 

Mailing Address (line 1) : INSTITUTION NAME

 

 

Mailing Address (line 2) : DEPARTMENT NAME

 

(*)

Mailing Address (line 3) :
STREET ADDRESS
( MAIL CODE, IF APPLICABLE )

 

(*)

City:

 

(*)

State / Prov:

If USA or Canada, use 2 letter abbreviation  

(*)

Zip Code:

 

(*)

Country:

 

(*)

Phone No.:

 If USA, Canada or the Caribbean, use this format   (999) 123-4567.
(  )    -  

If international, do not exceed 20 characters.

 

 

Ext No.:

 

 

Fax No.:

 If USA, Canada or the Caribbean, use this format   (999) 123-4567.
(  )    -  

If international, do not exceed 20 characters.

 

(*)

E-mail:


Please provide ONLY ONE e-mail address.
 

 

Secondary Contact E-mail:


Please provide ONLY ONE e-mail address.
 

* Primary Author Information *

(*)

Are you the primary author?:

 

 

 

If you selected 'No', please provide the following information (**):
(otherwise leave BLANK)
 

 

(**) Full Name:


eg:  John I. Smith MD, PhD, FACS
 

 

(**) Phone:

 

 

(**) Fax:

 

 

(**) E-mail:


Please provide ONLY ONE e-mail address.
 

iii - Co-Author(s) Information ( 9 limit )

IMPORTANT NOTE
A unique e-mail address is required for each identified co-author.

Include ALL degrees and credentials for each identified co-author.

Co-author names should be entered in the exact order and format they should appear in the abstract because this is how they will be printed in program materials.

Co-authors will be notified by email of this abstract submission.

1.)  Last Name:      First Name and M.I.:  Degrees/Credentials:
                  Email:   

2.)  Last Name:      First Name and M.I.:  Degrees/Credentials:
                  Email:   

3.)  Last Name:      First Name and M.I.:  Degrees/Credentials:
                  Email:   

4.)  Last Name:      First Name and M.I.:  Degrees/Credentials:
                  Email:   

5.)  Last Name:      First Name and M.I.:  Degrees/Credentials:
                  Email:   

6.)  Last Name:      First Name and M.I.:  Degrees/Credentials:
                  Email:   

7.)  Last Name:      First Name and M.I.:  Degrees/Credentials:
                  Email:   

8.)  Last Name:      First Name and M.I.:  Degrees/Credentials:
                  Email:   

9.)  Last Name:      First Name and M.I.:  Degrees/Credentials:
                  Email:   

BEFORE SUBMITTING THIS FORM, PLEASE CONFIRM THE FOLLOWING :
1. Review abstract text for accuracy and completeness.
2. Review all author information for accuracy, completeness and ensure names are in the correct order.
3. Check the box below
(*) As the first-named author (or agent acting on behalf of the first-named author), I verify the following is true:
1. It is my intent to submit this research to the Medical Student Program Poster Session.

2. All author/co-author information is accurate, complete and in the correct order (each co-author is represented in direct relation to the amount of research conducted in the abstract, from the most to the least).

3. I am authorized to submit this research on the behalf of all of the named co-authors and the institution where the research originated, and that no part of this submission infringes upon any copyright or other intellectual property or proprietary right of any third party.
If you will be submitting a table for this abstract, just follow the instructions on following web page
after submitting this form.
 


NOTE:
( Click this button ONCE )


CAUTION:
( This will erase all your responses )