SER - Poster Abstract Submission

Poster Abstract Submission Instructions

Submission deadline: May 31^st, 2021 (midnight EDT)

Posters approved for presenting must have at least one author with a paid registration attending the conference for the poster to be displayed.

Award recipients will be solely responsible for all federal, state and/or local taxes associated with the scholarship. The first place winner of $1000 will be required to complete an IRS W-9 before receiving payment.

NOTE: If you have multiple authors, COI information must be completed for each author listed on the poster.

NOTE: It is recommended to print the blank submission form to review prior to completing. Once you have started the application it cannot be saved. If this page is closed without submission, all information entered will be deleted.

Print a blank copy of this form now.

Fields with * are required. Complete all other fields as appropriate or enter "N/A" if not applicable.

*Person submitting this form:

*Email:

*Full Name:

*Phone:
*Phone type: Home Work Mobile

*Poster / Abstract Information:

*Poster Title:

*Poster Category:

*Abstract Text: (300 words or less)

References (limited to top five most pertinent citations)

Do not include any URLs

ref 1:

ref 2:

ref 3:

ref 4:

ref 5:

*Is this poster sponsored by Industry?
Yes No

*Has this poster been presented at any other conference?
Yes No
If yes, conference name and dates:

*Author Information:

*Number of Authors:
(Conflict of Interest information is required for each author - complete below. In the event there are more than 10 authors, contact bhe@serwocn.org for additional form)

*Primary Author Name, Contact and Disclosure

*Name of Presenter:

*First Name:

*Last Name:

*Degree/Title:
(List most current, highest degree first, then licensure and certification credentials)

*Employer:

*Address:

*City:

*State: *Zip:

*List at least one phone number:

Work Phone:

Cell Phone:

Home Phone:

*Email Address:

*Experience: Briefly describe your professional experience and/or expertise that qualifies you for this educational activity:

*Release I certify this poster presentation will not suggest or otherwise endorse the use of any products. I understand my presentation may be included in a conference summary or be used in other ways deemed appropriate by the Southeast Region of the WOCN^® Society.

I have read and agree to the terms and conditions listed above

No (disqualifies Poster)

Conflict of Interest Disclosure (Primary Author)

I hereby state:

I have no conflicts of interest
I have the following conflicts of interest

I have received sponsorship from:

I am employed by industry:

I have received an honorarium/fee from a company associated with this poster:

Any other potential conflict:

*In lieu of signature, by checking this box I certify the information provided herein is true and accurate:
Agree: Date:

Disclosure Author #2

First name: Last name:

   Degree/Title:
   (List most current, highest degree first, then licensure and certification credentials)

Employer:
City / State:

Conflict of Interest (Author #2)

I hereby state:

I have no conflicts of interest
I have the following conflicts of interest

I have received sponsorship from:

I am employed by industry:

I have received an honorarium/fee from a company associated with this poster:

Any other potential conflict:

*In lieu of signature, by checking this box I certify the information provided herein is true and accurate:
Agree

Disclosure Author #3

First name: Last name:

   Degree/Title:
   (List most current, highest degree first, then licensure and certification credentials)

Employer:
City / State:

Conflict of Interest (Author #3)

I hereby state:

I have no conflicts of interest
I have the following conflicts of interest

I have received sponsorship from:

I am employed by industry:

I have received an honorarium/fee from a company associated with this poster:

Any other potential conflict:

*In lieu of signature, by checking this box I certify the information provided herein is true and accurate:
Agree

Disclosure Author #4

First name: Last name:

   Degree/Title:
   (List most current, highest degree first, then licensure and certification credentials)

Employer:
City / State:

Conflict of Interest (Author #4)

I hereby state:

I have no conflicts of interest
I have the following conflicts of interest

I have received sponsorship from:

I am employed by industry:

I have received an honorarium/fee from a company associated with this poster:

Any other potential conflict:

*In lieu of signature, by checking this box I certify the information provided herein is true and accurate:
Agree

Disclosure Author #5

First name: Last name:

   Degree/Title:
   (List most current, highest degree first, then licensure and certification credentials)

Employer:
City / State:

Conflict of Interest (Author #5)

I hereby state:

I have no conflicts of interest
I have the following conflicts of interest

I have received sponsorship from:

I am employed by industry:

I have received an honorarium/fee from a company associated with this poster:

Any other potential conflict:

*In lieu of signature, by checking this box I certify the information provided herein is true and accurate:
Agree

Disclosure Author #6

First name: Last name:

   Degree/Title:
   (List most current, highest degree first, then licensure and certification credentials)

Employer:
City / State:

Conflict of Interest (Author #6)

I hereby state:

I have no conflicts of interest
I have the following conflicts of interest

I have received sponsorship from:

I am employed by industry:

I have received an honorarium/fee from a company associated with this poster:

Any other potential conflict:

*In lieu of signature, by checking this box I certify the information provided herein is true and accurate:
Agree

Disclosure Author #7

First name: Last name:

   Degree/Title:
   (List most current, highest degree first, then licensure and certification credentials)

Employer:
City / State:

Conflict of Interest (Author #7)

I hereby state:

I have no conflicts of interest
I have the following conflicts of interest

I have received sponsorship from:

I am employed by industry:

I have received an honorarium/fee from a company associated with this poster:

Any other potential conflict:

*In lieu of signature, by checking this box I certify the information provided herein is true and accurate:
Agree

Disclosure Author #8

First name: Last name:

   Degree/Title:
   (List most current, highest degree first, then licensure and certification credentials)

Employer:
City / State:

Conflict of Interest (Author #8)

I hereby state:

I have no conflicts of interest
I have the following conflicts of interest

I have received sponsorship from:

I am employed by industry:

I have received an honorarium/fee from a company associated with this poster:

Any other potential conflict:

*In lieu of signature, by checking this box I certify the information provided herein is true and accurate:
Agree

Disclosure Author #9

First name: Last name:

   Degree/Title:
   (List most current, highest degree first, then licensure and certification credentials)

Employer:
City / State:

Conflict of Interest (Author #9)

I hereby state:

I have no conflicts of interest
I have the following conflicts of interest

I have received sponsorship from:

I am employed by industry:

I have received an honorarium/fee from a company associated with this poster:

Any other potential conflict:

*In lieu of signature, by checking this box I certify the information provided herein is true and accurate:
Agree

Disclosure Author #10

First name: Last name:

   Degree/Title:
   (List most current, highest degree first, then licensure and certification credentials)

Employer:
City / State:

Conflict of Interest (Author #10)

I hereby state:

I have no conflicts of interest
I have the following conflicts of interest

I have received sponsorship from:

I am employed by industry:

I have received an honorarium/fee from a company associated with this poster:

Any other potential conflict:

*In lieu of signature, by checking this box I certify the information provided herein is true and accurate:
Agree

Poster Abstract Submission

Poster Abstract Submission

Poster Abstract Submission Instructions

NOTE: It is recommended to print the blank submission form to review prior to completing. Once you have started the application it cannot be saved. If this page is closed without submission, all information entered will be deleted.

*Person submitting this form:

*Poster / Abstract Information:

*Author Information:

Note: If the form does not submit, go up the page to make sure you've completed all required fields.