Poster Abstract Submission Form

Submission deadline: Extended to July 28, 2019 (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 a IRS W-9 before receiving payment.

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

Suggestion: Print a blank copy of this form before starting the application to become familiar with the requirements.

Instructions

We recommend completing this form on a computer or tablet (not a phone).
Fields with * are required. Complete all other fields as appropriate or enter "N/A" if not applicable.
Use the TAB key to move between fields. (pressing enter will activate the submission)

Due to SPAM filters, DO NOT show full URLs (links) in the Abstract Text.

Instead, replace the "http://www." with "ATAT", and replace the "." with "DOTDOT"
We will then convert the link accordingly
Example: ATATserwocnDOTDOTorg


(300 words or less)


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

Due to SPAM filters, DO NOT show full URLs (links) in the citations.

Instead, replace the "http://www." with "ATAT", and replace the "." with "DOTDOT"
We will then convert the link accordingly
Example: ATATserwocnDOTDOTorg
Or you may send an email with the reference links to bhe@serwocn.org.

ref 1:
ref 2:
ref 3:
ref 4:
ref 5:


  

  




Disclosure: Primary Author Name, Contact and Disclosure

First Name:
Last Name:
* Degree/Title:
(List most current, highest degree first, then licensure and certification credentials)
* Organization / Affiliation:
* Address:
* City:
* St:
* Zip:

  * List at least one phone number

WorkPhone:
CellPhone:
HomePhone:
* Email Address:
* Experience: Briefly describe your professional experience and/or expertise that qualifies you for this educational activity:

I certify this poster presentation will not suggest or otherwise endorse the use of any product. 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.


Conflict of Interest Disclosure (Primary Author)


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:


   

Conflict of Interest ( Author #2)


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:
   

Conflict of Interest (Author #3)


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:
   

Conflict of Interest (Author #4)


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:
   

Conflict of Interest (Author #5)


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:
   

Conflict of Interest (Author #6)


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:
   

Conflict of Interest (Author #7)


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:
   

Conflict of Interest (Author #8)


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:
   

Conflict of Interest (Author #9)


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:
   

Conflict of Interest (Author #10)


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:

 


  

If this form does not submit, scroll up and complete any missing required information.

If you need assistance with this form, please contact: webmaster@serwocn.org.

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