80 Years of Education & Humanitarian Service

Scholarship Submission 2021

ICS-US Section 2021 Research Scholarship Competition
Application Submission Form

Limit 1 submission per person

Abstract Title
Please submit in Title format. (Do NOT use all CAPS)
Example: Laparoscopic Management of Pancreatic Pseudocysts *
Select primary specialty to which this abstract applies. *

Applicant Information.
Note that only the applicant (submitting author) will be allowed to present at the ICSUS meeting, last minute substitutions are not permitted. Only the initial applicant will be eligible for award consideration.

FirstName *
LastName *
Degrees (MD, DO, PhD, etc.) *
Please indicate your
educational status *
Street Address *
City *
State *
Zipcode *
Enter the primary phone number where
submitting author can be contacted *
Type of Phone Number *
Enter email address for applicant.
Please note that email will be the primary method of communication.
Provide an email address that you check regularly. *
List your professional affiliations.
Example: Professor of Surgery, University of Illinois, Chicago
Will be included in printed program as submitted.
Where was the research conducted? (Name and location of Institution) *
Enter names and titles of co-author(s).
Note: Co-authors cannot make oral presentations on behalf of the submitting author.
No last minute substitutions will be permitted.
Only submitting author is eligible to receive a prize and only if submitting author presents research.

Note: All co-authors listed must submit a financial disclosure form indicating
whether or not they have a relationship with a commercial entity. It is the 
responsibility of the submitting author to ensure all co-authors submit a
financial disclosure as required.

Co-authors may submit their disclosure by visiting www.ficsonline.org/FDG

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

1. Abstract should not exceed 500 words.
2. Abstract should consist of four paragraphs as identified by the field headings below.
3. Be sure to include paragraph headings (purpose, methods, results, conclusions) in the field text.
4. Submission must be research based to qualify for awards. 

Enter the abstract PURPOSE in the space below. *
Enter the abstract METHODS in the space below. *
Enter the abstract RESULTS in the space below. *
Enter abstract CONCLUSIONS in the space below.


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 of individual in control of content. 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 the relationships 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 or peer-reviewer 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 activity.

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.

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 (speaker, consultant, etc.) and name of company.
This Presentation: *

Clear Selection
Off-Label Procedure(s)/Product(s) under investigation include:
Please provide the name of your Residency Program Director or Coordinator (or equivalent program representative for Fellows and Medical Students)
To be used for verification of your status in an approved program. *
Name of the Institution where your program is conducted. *
Program Director Phone Number *
Program Director Email *
Enter your name and the date below.
By clicking submit you acknowledge that you are digitally signing this document and
are legally bound as if you submitted this information in print form. *
Date *

As a participant in the research scholarship competition you will be considered a speaker in our program. 
Please review the Speaker Guidelines carefully before submitting.

Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.


ICS-US Section
83rd Annual Surgical Update

April 28-30, 2022
Renaissance Downtown Hotel - Providence, Rhode Island






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