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Presentation Proposal Form 2018

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Please complete this form completely before submitting.

ICS - US Section 2018 Presentation Proposal Form
Also use this form for AANOS submissions.

If you are completing this form after October 1, 2017 please be sure you were directed to this page by ICSUS staff. General submissions will not be accepted after October 1st.

Presentation Title
Please submit in Title format.
Example: Laparoscopic Management of Pancreatic Pseudocysts
Title will be published as submitted. *
Select primary specialty to which this presentation applies. *
If other Specialty indicate here...

Personal Information
Note that last minute speaker substitutions will not be permitted.
Any speaker changes must be submitted and approved at least 30 days
in advance of the meeting in order to obtain relevant information about the speaker.

FirstName *
LastName *
Degrees (MD, DO, PhD, etc.) *
List your professional affiliations.
Example: Professor of Surgery, University of Illinois, Chicago
Will be used in printed program as submitted. *
Contact Information

Street Address *


City *


State *


Zipcode *
Enter the primary phone number where you can be contacted. *
Type of Phone Number *
Enter your email address.
Please note that email will be the primary method of communication.
Provide an email address that you check regularly. *
If submission is research based, enter the institution name(s) and location(s) where the research was conducted.

Enter a description of your presentation in the fields below using the following guidelines. 
(Use copy and paste to transfer information from MS Word or other program.)

Description should include information about ...

 ... the problem / surgical intervention the presentation covers.
 ... why the audience needs to know this information.
 ... what the learner will be able to accomplish after the presentation.
 ... how the audience will benefit from the presentation.

If presentation is research based description should include 4 specific paragraphs that cover the Purpose, Methods, Results and Conclusions of the author.

Description should not exceed 500 words.

Using the guidelines above enter a description of your presentation in the fields below. Description can be submitted using only one field. Additional fields are provided for larger descriptions that may exceed field limitations. *
Additional description here...
And here...

Needs Assessment Data

In the space below, please indicate how the need for this presentation was brought to your attention. 
(Possible ways are: review of journal article, medical audit, advice from or discussion with experts, new technology, discussion with colleagues during staff meetings, survey results, personal experience, etc.)

List sources here.

FINANCIAL DISCLOSURES

The Importance of Identification.  In order for the audience at a CME activity sponsored by the International College of Surgeons-United States Section (ICSUS) to evaluate information, analysis and opinions presented during the activity, it is crucial that the audience be informed of ALL financial relationships of a planner, speaker, author, peer-reviewer or spouse.  All planners, speakers, authors  and peer-reviewers for a CME activity are required to submit FULL DISCLOSURE of ALL financial relationships prior to the CME activity including those of a spouse or domestic partner.

Financial 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.

A conflict of interest (COI) occurs when there is a divergence between an individual's private interests and his or her professional obligations to ICSUS such that an independent observer might reasonably question whether the individual's professional actions or decisions are determined by considerations of personal gain, financial or otherwise. A conflict of interest depends on the situation, and not on the character or actions of the individual.

A COI is present when a planner, speaker, author, peer-reviewer or spouse has both a current financial relationship with a commercial interest and the opportunity to affect content relevant to products or services of that commercial interest. Conflicts of interest are identified through an analysis of the information disclosed and an understanding of the planned content of the CME.

In order for the ICSUS to determine whether a conflict of interest exists, you must provide information about all financial relationships you have with a commercial interest. This includes relationships with companies that may not have an interest in your presentation, but with which you have a relationnship. ICSUS must be informed of all relationships to independently make the determination as to whether or not the relationship is relevant to your presentation.

I have read the policies (click here to view complete policy and FAQs) regarding “relevant financial disclosure” and I attest that:     

To the best of my knowledge: *

Clear Selection
List Financial Relationship(s)
Include relationship (paid speaker, consultant, shareholder, etc.) and name of company.

Speakers are also required to report if their presentation includes discussion(s) of investigational products or products not labeled for use.

Off-Label Disclosure:  (Including Generic Trade Names and Reporting Scientific Research) Presentations must give a balanced view of options.  Use of generic names in your presentation will contribute to this impartiality. Presentations supported by a commercial entity reporting the results of scientific research must conform to the generally accepted standards of experimental design, data collection and analysis.   When an unlabeled use of a commercial product, or an investigational use not yet approved for any purpose is discussed during an educational activity it is required that the speaker disclose that the product is not labeled for the use under discussion or that the product is still investigational.

This Presentation: *

Clear Selection
Off-Label Procedure(s)/Product(s) under investigation include:
By clicking the following button and submitting the information above you acknowledge that you are digitally signing this document and are legally bound as if you submitted this information in print form.

In addition, by submitting this form you agree that you have reviewed the Speaker Guidelines and will comply with the terms and conditions contained therein. This agreement includes, but is not limited to, meeting submission deadlines for additional information that will be requested. Failure to comply with deadlines or respond to requests will result in removal from the program.
*

Clear Selection

Click here to review Speaker Guidelines

Enter your name *
Date *



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81st Annual Surgical Update of the United States Section

May 2-4, 2019

Nemacolin Woodlands Resort
Farmington, Pennsylvania
Approximately 90 minutes from the Pittsburgh Airport

 

 

 

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