ASPN Abstract Submission Form

ASPN Abstract Submission Form

Submission Deadline: April 1, 2023
Abstract Title

Primary Presenter
Primary Presenter Name

First Name Last Name
Credentials
Affiliation
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com

Co-Presenter
Co-Presenter Name

First Name Last Name
Credentials
Affiliation
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com

Co-Presenter 2
Co-Presenter 2 Name

First Name Last Name
Credentials
Affiliation
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com

Co-Presenter 3
Co-Presenter 3 Name

First Name Last Name
Credentials
Affiliation
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com

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Please attach your abstract which includes: Introduction, Objectives, Materials and Methods, Results, Conclusion, References (Author 1, Author 2, Author 3 et al. Title. Journal Year. Volume: start page-end page), Acknowledgements - please acknowledge any funding source and contributors to the research, Figure and Table Legend. Abstract should be no more than 500 words. References can be separate to not go towards the word count.

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Please upload and also send abstract to Lakyn.mantra@gmail.com

Please email your abstract to lakyn.mantra@gmail.com which includes: Introduction, Objectives, Materials and Methods, Results, Conclusion, References (Author 1, Author 2, Author 3 et al. Title. Journal Year. Volume: start page-end page), Acknowledgements - please acknowledge any funding source and contributors to the research, Figure and Table Legend. Abstract should be no more than 500 words. References can be separate to not go towards the word count.
Disclosures
Do any of the authors of this abstract have any commercial relationships to disclose? - If yes, please complete the Disclosure of Commercial Relationships.

YesNo
Is any device or drug required FDA approval identified as an important component of your presentation? - If yes, please complete the FDA Disclosure Form.

YesNo
Signature

Clear
Name

First Name Last Name
Date

MonthDay Year
Date
By submitting this abstract, the presenting author certifies the following:

The identical abstract has not been submitted to any other meeting. The material has not been accepted for publication prior to this submission. All the listed presenters have reviewed this abstract and agree to its submission. Upon acceptance, the presenting author accepts the commitment to possibly present the abstract at the ASPN 2023 Conference.
Presenter Biographical Form

This information must be submitted for the Primary Presenter only. Please type the information with your name and credentials exactly as you want them to appear in the published materials.
Name

First Name Last Name
Credentials
Professional Title
Facility
Work Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone Number
Please enter a valid phone number.
Work Fax Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
Academic Preparation/Institution
Please include: Relevant Training and Experience in this Area
Disclosure of Financial Relationships

All authors submitting abstracts for publications are required to disclose any relationships with industry that may direct bearing on relevant subject matter. The primary presenter must disclose any author/presenter who has relevant financial interest or other relationships occurring with the past 12 months with commercial companies or organizations.
Author Name

First Name Last Name

	Company	Company	Company	Company
Board Member/Trustee
Consultant/Advisor
Employee
Investigator
Investment/Stock Options/Shares
Meeting Participant/Lecturer
Owner
Scientific Study/Trial
Other (please specify)

Additional Form if needed
Author Name

First Name Last Name

	Company	Company	Company	Company
Board Member/Trustee
Consultant/Advisor
Employee
Investigator
Investment/Stock Options/Shares
Meeting Participant/Lecturer
Owner
Scientific Study/Trial
Other (please specify)

Additional Form if needed
Author Name

First Name Last Name

	Company	Company	Company	Company
Board Member/Trustee
Consultant/Advisor
Employee
Investigator
Investment/Stock Options/Shares
Meeting Participant/Lecturer
Owner
Scientific Study/Trial
Other (please specify)

Additional Form if needed
Author Name

First Name Last Name

	Company	Company	Company	Company
Board Member/Trustee
Consultant/Advisor
Employee
Investigator
Investment/Stock Options/Shares
Meeting Participant/Lecturer
Owner
Scientific Study/Trial
Other (please specify)

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FDA Disclosure

If a device or drug requiring FDA approval is identified as an important component of your presentation, please list the device/drug and indicate the FDA status as either: Approved, Investigational Device/Drug, Not approved for distribution in the United States.
Device/Drug blanks Status blank
Device/Drug blanks Status blank
Device/Drug blanks Status blank
Device/Drug blanks Status blank
Device/Drug blanks Status blank
Device/Drug blanks Status blank
Should be Empty:

ASPN Abstract Submission Form

Please upload and also send abstract to Lakyn.mantra@gmail.com

Disclosures

By submitting this abstract, the presenting author certifies the following:

Presenter Biographical Form

Disclosure of Financial Relationships

FDA Disclosure