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2010 Call for Submission Application Form

Status of Primary Presenter

Health Care Professional

Fellow

Resident

Student

Other: (Indicate your status if "other.")

Author Information

Salutation:	Dr. Mr. Ms. Mrs.
First name:
Initial:
Last name:
Degree(s):	Format for degrees: MD, PhD, MSIII
Institution/affiliation:
Department:
Mailing address:
City:
State:	Format for state: NY
Zip code:
Work phone:	Format for work phone and fax numbers: (555)123-4567
Extension:
Fax:
E-mail address:

Additional Authors

Please be sure to provide complete authors' names and degrees and indicate if they will be presenting if this submission is accepted. If you have more than five authors, please send additional information in an e-mail message to lisa.schwieterman@fmec.net. Include each author's name and e-mail address and whether he/she will be presenting. Please list the correct order of ALL authors in your message.

Second author name and degree(s):
This author will be presenting:
E-mail address:

Third author name and degree(s):
This author will be presenting:
E-mail address:

Fourth author name and degree(s):
This author will be presenting:
E-mail address:

Fifth author name and degree(s):
This author will be presenting:
E-mail address:

We would like to use a variety of social media to support this year's meeting. Please check the box beside each internet tool you currently use:

Facebook

Twitter

Category of Submission

See the Submission Category Descriptions for more information (197 KB).

Workshop

Seminar

Research Presentation

Poetry of Life Presentation

Paper

Poster

Networking Breakfast

Common Interest Breakfast Discussion

Title of Submission or Discussion Topic

Format for title: Title of My Submission

Audio/Visual Requirements

Our conference is charged a fee for all A/V equipment. Please be judicious with requests. Other types of AV equipment not listed here must be provided by the presenter(s). If your AV requirements change from your initial submission, please notifiy us immediately.

Single slide projector:	No Yes
Overhead projector:	No Yes
Flip chart:	No Yes
TV/VCR:	No Yes
LCD Projector:	No Yes

Abstract (200 words or fewer summary)

You may type or paste your abstract into the field provided here. Please send your complete proposal and a CV from the primary presenter as attachments to lisa.schwieterman@fmec.net. Be sure that the title and category of your presentation are at the top of your e-mail message.

A proposal is an expanded version of the abstract. It must be typed single-spaced and should not exceed two pages. A submission may not be accepted into the conference category requested if a proposal is not included in the submission. Please refer to the electronic Call For Submissions brochure pages for further detailed explanations.

Workshop Proposals Must Include

A statement of rationale and objectives
The content of the presentation
Methods for and extent of involving participants
A breakdown of time utilization

Seminar Proposals Must Include

A statement of rationale and objectives
The content of the presentation
Methods for and extent of involving participants
A breakdown of time utilization

Research Presentations Must Include

Statement of problem addressed and its significance
Background and summary of the literature review
Methodology used with attention to research design and problems of measurement
Summary of results
Summary of discussion and conclusions

Poety of Life Presentations (New Venue in 2010)

The Family Medicine Education Consortium (FMEC) announces a new venue by which medical students, residents and practicing physicians may present patient stories they have recognized in the course of their relationships with their patients. Accepted presenters will be allowed a maximum of five minutes and five slides to introduce a memorable encounter/moment/relationship which has inspired their own passion to serve and care for others.

Presentations will be videotaped in a breakout meeting. The audience will consist of a small group of reviewers. The video-recording will be made available for others to view at a later date, e.g. on YouTube, the Family Medicine Digital Resource Library and the FMEC website. Up to 10 presentations will be selected for presentation at this year’s meeting. Here is an example of a Poetry of Life presentation from the 2009 meeting. (Please note: this video-recording was completed under poor lighting conditions)

Ms. Carol Dwan

Submissions are especially encouraged by medical students and residents who have been moved by an experience which has changed their lives and led to an even greater enthusiasm to pursue our healing profession. Potential personal identifiers of the patient must specifically be excluded.

A submission involves a single spaced, one page description of your presentation. A peer-review process will be used to select the 10 best submissions for presentation at the meeting.

Submissions should be made only by those who will attend the 2010 FMEC Northeast Region meeting. An award for best presentation in this category will be conferred on Sunday morning at this meeting. Direct any questions to Richard Colgan, MD.

Paper Proposals Must Include

A statement of rationale and intent
A summary of the content

Poster Proposals Must Include

Rationale
Methods and content
Findings and conclusions for research projects

Attached files should be in Microsoft Word (.doc), rich text format (.rtf), or text format (.txt). If you wish to preserve special formatting (tabs, fonts, tables, etc.), please send your files as .doc or .rtf attachments.

If you are not able to send attachments to an e-mail message, please copy your complete proposal and paste it into the body of the e-mail message, then repeat for your CV.

DISCLOSURE OF RELATIONSHIPS WITH COMMERCIAL COMPANIES

Family Medicine Education Consortium, Inc. must insure balance, independence, objectivity, and scientific rigor in all its educational activities. All speakers are expected to disclose to the audience any significant financial interest or other relationship with 1) the manufacturer of any commercial product or the provider of commercial services discussed in your educational presentation, or both and 2) any supporters of the conference.

(Significant financial interest or other relationship may include grants or research support, employee, consultant, stockholder, member of speaker’s bureau, owner of a company or product, designer of a product, etc.)

1. Within the past twelve months, I have received support from or have had a relationship with a commercial party related directly or indirectly to the subject of my presentation.

Yes No

If yes, please check all that apply:

Nature of Relationship:	Company
Speaker’s Bureau
Research Grant
Stockholder
Employment Affiliation
Other

2. Will you discuss any off-label uses?

Yes No

If yes, please identify the product and the unlabeled use.

3. Will you discuss any investigational uses?

Yes No

If yes, please identify the product and the investigational use.

4. Have you been asked to promote or market any products?

Yes No

If yes, what products?

5. My participation does not infringe upon any copyright or other intellectual property or proprietary right of any third party. I have obtained appropriate permission to reprint any portion of my presentation.

Yes No

6. If patient identifying information is used, I have obtained the necessary patient release signatures.

Yes No

I certify that this information is true and correct. I understand that I am responsible for ensuring that any discussion of investigational and/or off-label uses of a product is disclosed to the audience.

NOTE: Disclosure information will be provided to the audience. Failure to complete this form will be noted as “Refusal to Disclose.”

Please use your browser's "Print" button to print a copy of the completed form for your records

Need help? Please send a message to lisa.schwieterman@fmec.net.

Data will be checked for completeness before being submitted.