Scholarship Submission 2024 US | International College of Surgeons, US Section

ICS-US Section 2024 Research Scholarship Competition
Application Submission Form

Limit 1 submission per person
Only for medical students and residents in the US

(Click HERE to apply if you are from outside the US)

Abstract Title
Please submit in Title format. (Do NOT use all CAPS)
Example: Laparoscopic Management of Pancreatic Pseudocysts
Title should be short and concise.
Note character limit below. Example has 49 characters. *
(Maximum characters: 500)
You have characters left.

Select primary specialty to which this abstract applies. *

Applicant (Presenter) 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.

Check here if you are or have applied to be a Junior ICS Fellow.

FirstName *

LastName *

Degrees (MD, DO, PhD, etc.) *

Street Address *

City *

State *

Zipcode *

Enter email address for applicant (speaker).
Please note that email will be the primary method of communication.
Provide an email address that you check regularly.
*

Enter the primary phone number where
submitting author can be contacted *

Type of Phone Number
*

Please indicate your
educational status *

List your professional affiliations.
Example: Resident, University of Illinois, Chicago
Will be included in printed program as submitted.
(Maximum characters: 2000)
You have characters left.

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 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

Where was the research conducted? (Name and location of Institution) *

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. *
(Maximum characters: 2000)
You have characters left.

Enter the abstract METHODS in the space below. *
(Maximum characters: 2000)
You have characters left.

Enter the abstract RESULTS in the space below. *
(Maximum characters: 2000)
You have characters left.

Enter abstract CONCLUSIONS in the space below.
(Maximum characters: 2000)
You have characters left.

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 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 an ineligible company 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 ineligible companies.

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

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.

To the best of my knowledge: *

I DO NOT have any financial relationships to report.

I DO have the following relationships to report...

Clear Selection

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

This Presentation: *

DOES NOT include information about product(s) not labeled for use or investigational

DOES include information about procedure(s)/product(s) not labeled for use and/or are investigational.
I understand that I must disclose this information to the audience prior to the presentation.

Clear Selection

Off-Label Procedure(s)/Product(s) under investigation include:

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 *

Fields marked with * are required.

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