Clinical and Professional Poster Session Abstract Submission Application

AAPA 2010 CLINICAL AND PROFESSIONAL POSTER SESSION ABSTRACT SUBMISSION APPLICATION

All asbtract submission forms must be received by 11:59 PM EST on
Friday, January 15, 2010

Submission Information:

* Submitting Author:

* AAPA ID #:

Membership Expiration Date:

Member Type:

Fellow

Student

Company Name (no acronyms):

Street Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

E-mail Address:

Student Affiliation:
If you are currently enrolled in an entry-level accredited PA program, please complete the information below.

Program Name:

Street Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Program Director's Name:

Author Information:
Authorship is substantial participation, which includes involvement in the conception and design or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published. Authorship is not acceptable if the author only provides encouragement, physical facilities, financial support, critiques, or editorial contributions.

First Author's Name:

AAPA ID #:

Membership Status:

Member

Non-Member

Second Author's Name:

AAPA ID #:

Membership Status:

Member

Non-Member

Third Author's Name:

AAPA ID #:

Membership Status:

Member

Non-Member

Fourth Author's Name:

AAPA ID #:

Membership Status:

Member

Non-Member

Fifth Author's Name:

AAPA ID #:

Membership Status:

Member

Non-Member

Sixth Author's Name:

AAPA ID #:

Membership Status:

Member

Non-Member

Abstract Category Selection:

Please select a category (select only one):
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Gallery Selection:

Please select a gallery (select only one):
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Clinical and Professional Gallery

Education Gallery

Student Gallery

Do you qualify for The Association of Postgraduate PA Programs (APPAP) award?

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Abstract Information:

Title:

Please provide (3) words that best suit the topic of research, i.e., tracheotomy, HIV, education, etc.

1.

2.

3.

Instructions for submitting abstract: Please exclude the name and affiliation of the authors when submitting your research. NOTE: Abstracts can be cut and pasted in the space below or attached in Word document format. 500 word limit.

Warning: not all browsers support file upload capabilities. Recent versions of Microsoft (4.0 and greater), Netscape (3.0 and greater), and AOL (4.0 and greater) support this feature. If you are not using a recent browser, please copy your abstract text in the box provided above.

Disclosure Policy and Declaration Statements:
Declaration is intended to protect all parties involved from any potential conflict that may arise from the presentation. The announcement of affiliations or financial arrangements gives participants full disclosure of facts from which they may form their own judgments. If you and/or any of the co-authors have received funding in support or sponsorship of your research, please provide the necessary information below.

Submitting Author's Name:

Non-declaration statement:

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I declare that neither I, nor any immediate family member, have a current affiliation or financial arrangement with the grantor and/or organization(s) that may have a direct interest in the subject matter of the above stated program.

Declaration Statement:

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I declare that either I, or my immediate family member, currently have an affiliation or financial arrangement with the grantor and/or any organization(s) that may have a direct interest in the subject matter of the above mentioned program.

Funding Types:

Abstract Acknowledgement:

Once you have successfully completed the submission application you will receive an e-mail of the results submitted, confirming receipt. Please re-type your e-mail address below. If you have not received confirmation in 24 hours, please contact Cheryl Holmes, Science and Education, cholmes@aapa.org or 703-836-2272.

* Indicates Response Required

Consultant	Employee
Grants/Research Support	Honorarium
Other Financial/Material Support	Speakers' Bureau
Stock Shareholder	Other (please specify)