MSS Submission Form

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MDMD, FACSDODO, FACSMBBSBABSOther
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Presenter Information
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FellowAssociate FellowResidentResearchMedical StudentOther
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Hennepin County Medical CenterMayo ClinicUniversity of MinnesotaOther
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About Your Submission
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AbstractCase Review
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Basic ScienceClinical Science
Cancer Paper Award

Note: Presenter must be a resident member.
My submission is eligible for the Cancer Paper Award?*

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Abstract Submission
Category*

Abdominal/LaparoscopyBariatric/ForegutBreastCardiac SurgeryColon and Rectal SurgeryEducationEndocrineEthicsGeneral SurgeryGeriatric/Palliative CareHepatobiliary and PancreasMilitaryOphthalmic SurgeryOtolaryngologyPediatric SurgeryPlastic & Maxillofacial SurgerySurgical EducationSurgical OncologyThoracic SurgeryTransplantation SurgeryTrauma/Burn/Critical CareUrological SurgeryVascular SurgeryOther
Title of Paper *
Authors *
Enter authors names as First Initial Last Name with a comma separating each author. No credentials or other punctuation. For example: A Smith, J Jones, W Miller
Introduction*
Methods*
Results*
Conclusion*
Case Review
Title*
Authors*
Enter authors names as First Initial Last Name with a comma separating each author. No credentials or other punctuation. For example: A Smith, J Jones, W Miller
Background*
Summary*
Case Description*
Discussion*
Conclusion*
Lessons Learned*
Upload one graph or chart only

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Speaker Disclosure Form
In accordance with ACCME regulations (ACCME Standard 3), the American College of Surgeons must ensure that anyone who is able to control the content of the activity has disclosed all financial relationships with any ineligible companies in the 24 months prior to their involvement in the educational activity.

Ineligible Company: Companies that are ineligible to be accredited in the ACCME system (ineligible companies) are those whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients.

Financial Relationships: Financial relationships are relevant if the following three conditions are met for the individual who will control content of the education: 1) a financial relationship, in any amount, exists between the person in control of content and an ineligible company; 2) the financial relationship existed in the last 24 months; 3) the content of the education is related to the products of an ineligible company with whom the person has a financial relationship.

All CME Planners and Speakers /Moderators/Discussants/Authors/Editors involved in the development and/or presentation of CME content must complete this form. This form must be updated whenever circumstances require. As relevant, all disclosure information for speakers must be revealed by a slide at the beginning of the presentation.
Select all that apply*

I am an owner, employee, or stockholder (not through a mutual fund or pension plan) of an ineligible company and there for am excluded from controlling content or participating as a planner or faculty in accredited education. For more information: ACCME Standard 3I do not have personal financial relationships with any ineligible companies as defined above.I do have financial relationship(s) with ineligible companies as defined above.
- ACCME Standard 3
- List the names of companies that you have a financial relationship with currently or have had in the last 24 months.
- Explain what you received (i.e. salary, honorarium etc.).
- Specify your role (i.e. consultant, board member, etc.)
Failure or refusal to disclose or the inability to mitigate an identified conflict will result in the withdrawal of the invitation to participate.

	Company Name	What I received?	For what role (the nature of the relationship)
Disclosure 1
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Disclosure 3
Disclosure 4

Please note that attesting to the following conditions are required:*

I agree that I will not directly accept honoraria, travel expenses, in-kind contributions, or any other compensation from ineligible companies in connection with this activity (Support provided with a letter of agreement may be permissible).If any of the information reported above changes, I will notify ACS immediately and update this form accordingly.
By typing my name below, I certify that I have identified and disclosed all financial relationships with any ineligible companies (in the last 24 months) and that all information provided herein is true and correct.*
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Call for Abstracts

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