FOEM General Competition Application Form

General Competition Application Form
Applicant's Information
Name*

First NameLast NameCredentials
ACOEP Membership Status*

StudentResidentAssociateActive (early attending, attending, military, etc.)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Current Level of Training*
Current Level of Training**
Dates of Training*
Institution Information
Institution Name*
City*
State*
Program Director Name:*

First NameLast NameCredentials
Program Director Email:*
example@example.com
Program Director Title:*
Program Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Project Information
Competition Choice:*
Please choose the competition that you are applying for – only one competition per project is accepted.
Project Title*
Project Authors*
List all contributing authors in order, including full names and relevant degrees or titles. The Principal Investigator (PI) must be listed last.
Official Presenter(s)*
IRB Status*

ApprovedExemptNot Applicable
If applicable, list IRB Reference Number
Prior Presentation or Publication*

YesNo
If yes, list details:
Funding/Conflict of Interest Disclosure
List any financial support or conflicts of interest relevant to this project. If none, enter “None.”
Upload your Files
Submissions MUST be in the format as outlined in the Competition Guidelines on the website.
Competition File Upload

Only pdf, .doc, and .docx formats are allowed.
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CPC Competition Faculty Discussant Information (Fall)

This section is only required for applicants selecting the CPC Competition.
Faculty Discussant Name

First NameLast NameCredentials
Faculty Discussant Title
Faculty Discussant Degree
Faculty Discussant Phone Number (Home/Cell)
Please enter a valid phone number.Format: (000) 000-0000.
Faculty Discussant Email
example@example.com
Faculty Discussant Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attestations - Please check all boxes to confirm your agreement:

I certify that all listed authors meet authorship criteria and participated sufficiently to take public responsibility for the content.I confirm that this submission has not been presented, published, or submitted elsewhere, or I have disclosed prior presentations in the form.I have disclosed any financial relationships or conflicts of interest in this form.If applicable, I confirm that IRB approval or exemption has been obtained for this study, or that it is not required according to institutional guidelines.I have obtained permission from all co-authors and my program director (if applicable) to submit this work to the FOEM competition.I agree to comply with all FOEM competition rules and guidelines.
AUTHORSHIP All persons meeting authorship criteria are listed as authors, and will certify that they have participated sufficiently in the work to take public responsibility for its content, including participation in the concept, design, analysis, writing, or revision of the manuscript. Furthermore, each author certifies that this material or similar material has not been and will not be submitted to any other publication before its appearance at the next national meeting of the American College of Osteopathic Emergency Physicians (ACOEP) without its prior, written approval. If this study has been or will be presented at any other national meeting, indicate the date of the meeting on a separate cover page. CONFLICT OF INTEREST I certify that any affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript are disclosed below or in the cover letter. If none, state “none” below. INSTITUTIONAL REVIEW BOARD APPROVAL (If applicable) An institution’s human or animal subject review committee must approve all studies involving human or animal subjects. If your institution’s ethical research protocols exempt your study from such approval, state below. To maintain blinded peer review, do not include the name of the institution when identifying the review committee in the Abstract. Institutional review board approval or exemption has been completed. This will verify that I am the primary author of the project named below and provide this paper as an entry into chosen competition. I swear and attest to receiving the permission of my program director and the all other authors of the research I am submitting. Check one option below. This check box will serve as an electronic signature.

I am the primary author of the project and I will agree to the publication of the project.I am the primary author of the project and I will abstain from the publication of the project.
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General Competition Application Form

Applicant's Information

Institution Information

Project Information

Upload your Files

CPC Competition Faculty Discussant Information (Fall)