Applicant's Information
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| First Name:* |
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| Home Address:* |
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| Zip Code:* |
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| Phone Number:* |
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| Year of Training:* |
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| Dates of Training:* |
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Institution Information
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| Institution Name:* |
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Program Director's Information
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| PD's First Name:* |
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| PD's Last Name:* |
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| PD's Degree:* |
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| PD's Title:* |
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| PD's Address:* |
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| PD's City:* |
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| PD's Zip Code:* |
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| PD's E-mail:* |
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Competition Choice
Please choose the competition that you are applying for – only one competition per project is accepted. |
| Competition:* |
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**If applying to the CPC Competition, Faculty Discussant information must be listed below. This information will be used to send blinded case abstracts to the Discussant, so please ensure that this is the home address (not the hospital) and the home/cell phone (not the hospital).
Faculty Discussant Information |
| FD's First Name: |
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| FD's Degree: |
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Project Information
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| Project Title:* |
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| Project Authors:* |
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(list all authors and applicable titles such as DO, MD, RN, etc. Principle Investigator should be listed last) |
| Official Presenter:* |
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(one presenter per project) |
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Electronic Signature
AUTHORSHIP
All persons meeting authorship criteria are listed as authors, and will certify that they have participated sufficiently in the work to take public responsibility for its content, including participation in the concept, design, analysis, writing, or revision of the manuscript. Furthermore, each author certifies that this material or similar material has not been and will not be submitted to any other publication before its appearance at the next national meeting of the American College of Osteopathic Emergency Physicians (ACOEP) without its prior, written approval. If this study has been or will be presented at any other national meeting, indicate the date of the meeting on a separate cover page.
CONFLICT OF INTEREST
I certify that any affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript are disclosed below or in the cover letter. If none, state “none” below.
INSTITUTIONAL REVIEW BOARD APPROVAL (If applicable)
An institution’s human or animal subject review committee must approve all studies involving human or animal subjects. If your institution’s ethical research protocols exempt your study from such approval, state below. To maintain blinded peer review, do not include the name of the institution when identifying the review committee in the Abstract. Institutional review board approval or exemption has been completed. |
This will verify that I am the primary author of the project named below and provide this paper to be judged by the Foundation for Osteopathic Emergency Medicine as an entry into the FOEM Competition chosen below. I swear and attest to receiving the permission of my program director and the all other authors of the research I am submitting. Check one option below. This check box will serve as an electronic signature. |
| Choose One:* |
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Upload only files pertaining to the competition you are applying for in the designated upload boxes below. |
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| New Innovations in Emergency Medicine Doc |
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| Case Study Poster Abstract |
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| Research Paper Abstract |
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| Research Paper |
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| Research Poster Abstract |
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| Oral Abstract |
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| CPC Case History |
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| CPC Diagnosis |
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| CPC Supporting Doc |
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