Roundtable Submission Form
*Required information
Submitter Contact Information – for correspondence*Name:
*Affiliation:
Agency/Department:
*Email Address:
PresenterInformation – Will be included in on-site program book
*Name:
Credentials:
*Affiliation:
Agency/Department:
*Address:
*City, State Zip:
*Phone:
Mobile:
*Author Information:
Enter all authors,including yourselfif you are an author, in the order you wish them to appear in the printed materials. Include credentials and affiliations. This information will be used in the on-site program book.
*Approval: By placing an “X” in the box to the left, I confirm that this submission has been approved by all authors and if accepted I confirm that at least one author will register to attend and present the abstract at the 2012National Oral Health Conference.
*Domain: Check the domain that best describes your abstract. Place an “X” by one of the following: / Community-based Intervention / Program Evaluation
Partnership / Research
Abstract Title:MUST BE IN ALL CAPS
*TITLE:
*Description: Must be limited to 250 words cumulatively. No exceptions.
*Source of funding: If no source of funding, please indicate “none”.
Please note, oral, poster and roundtable presenters selected to present at the NOHC must register and pay the applicable registration fees. Only Invited Session presenters qualify to register under the speaker registration category.
*Conflict of Interest Declaration:
Having an interest in or an affiliation with a corporate organization does not necessarily prevent you from making a presentation, but the relationship must be made known to the audience. Failure to disclose or a false disclosure will require AAPHD (the approved continuing education provider for the American Dental Association and the Academy of General Dentistry) to remove you from the program and to identify a replacement for your participation.
Please complete the applicable statement below with your signature and date.
Electronic signatures are acceptable
I, the undersigned, declare that the author(s) or immediate member of their family have a financial arrangement or affiliation with a corporateorganization offering financial support or grant monies for this continuing dental education program or have a financial interest in any commercial product(s) or service(s) that will be discussed in the presentation.
Example: John D Smith, DDS, receives an honorarium from ABC Dental Supply.
Example: Jane R Jones, DMD, MPH, receives a grant/research support from XXXX.
Author Affiliation/Financial Interest Corporate Organization
Signature of abstract submitter(Electronic/typed signature is acceptable)Date
OR
I, the undersigned, declare that neither the author(s)nor any immediate member of their family have a financial arrangement or affiliation with any corporate organization offering financial support or grant monies for this continuing dental education program, nor have a financial interest in any commercial product(s) or service(s) which will be discussed in the presentation.
Signature of abstract submitter(Electronic/type signature is acceptable)Date
Please submit the Roundtable Submission Form in Word format (no pdfs please) to Sandi Steil, , no later than December 29, 2014
You will receive an e-mail acknowledgement of your roundtable submission.
Should you have any questions, please contact Sandi Steil at 217-529-6503.