Abstract Submission Form
LSRC 44th Educational Meeting and Exhibits
Open Forum, April 23-24, 2014
Section A (Abstract Information)
1. Presenting First Author
Last name:
First name:
Middle initial:
E-mail address:
2. Presenter status:
Non-student
Student
3. Presenter affiliation:
4. Presentation title:
5. Full name(s) of co-authors:
6. List two key words that best describe your proposed presentation.
7. Abstract Category (check only one)
Original Scientific Research Study Abstract
Method, Device, or Protocol Evaluation Abstract
Unique Case Report Abstract
Literature Review Abstract
8. Research funding source(s): Note: abstracts of research funded by tobacco industry sources
will not be considered. If none, indicate none.
7. Below, type an abstract (300 word limit) of your proposal for review by the Review
Committee.
8. If the abstract is accepted and placed on the Open Forum program, I will personally appear
to present it, OR, in the case of extenuating circumstances, I will arrange for the proposal
to be presented by a substitute.
Yes
No
Section B (Abstract Author Disclosure)
Conflict of Interest
o
The conflict of interest policy of LSRC is consistent to that of RESPIRATORY CARE.
o
The Review Committee will decide whether the presence of conflicts of interest affects the
suitability of the abstract for acceptance.
o
Disclosure of relationships will not necessarily affect the review of the abstract.
o
Having conflicts of interest is not considered unethical. However, not disclosing such
conflicts of interest is unethical.
o
Disclosures of potential conflicts of interest should be for the previous 2-year period.
o
Authors must provide full disclosure of all potential conflicts of interest. The type of
relationship (e.g., consultant, speaker, employee, etc.) and the monetary amount need not be
specified.
The following conflicts of interest must be addressed by the presenting author on behalf of each
entity involved in the proposed abstract study. This includes, but is not necessarily limited to,
affiliated or sponsoring institution, presenting author, co-authors, research/nurse coordinators,
technicians, post-docs/ fellows/ residents, and other students working on the project.
For the previous 2-yr period, does any study member or your institution:
1. Have an equity interest in or is an employee of the company that is sponsoring this research or in a
company with similar or competing products? Mark "No" if there is no financial sponsor for this
study.
No
Yes, explain
2. Serve as a consultant or serve on the Board of Directors or an Advisory Board for the sponsor or any
other company in your field of research? Mark "No" if there is no financial sponsor for this study.
No
Yes, explain
3. Have any patents, whether planned, pending or issued, broadly relevant to the work?
No
Yes, explain
4. Receive any royalties, honoraria, gifts, or services from a third party (government, commercial,
private foundation, etc.) related to any aspect of aspect of the submitted work (including but not
limited to grants, study design, manuscript preparation, statistical analysis, donation of equipment
and supplies, etc.)?
No
Yes, explain
5. Are there other relationships or activities that readers could perceive to have influenced, or that
give the appearance of potentially influencing, what you wrote in the submitted work?
No
Yes, explain
To the best of my understanding the above questions of conflicts of interest have been answered
truthfully.
No
Yes
Abstract proposal submission form due by 5:00 pm on Tuesday, April 1, 2014