Local Case Online Submission Form
Submission Deadline: Wednesday, August 15, 2018

Submitting Author Contact Information
First Name   M.I.   Last Name
Hospital/Affiliation
Address
City
State
Zip Code
Email
Phone
Please select phases of care you would like to highlight
Prehospital
Trauma Bay
PICU
Floor
Rehab
Long-term follow-up
 
Title
 
Brief Clinical Synopsis (500 words max)
Presenting Author Disclosure Information
 
In accordance with ACCME regulations, the American College of Surgeons, as the accredited provider of this activity, must ensure that anyone who is in a position to control the content of the education activity has disclosed to us all relevant financial relationships with any commercial interest (see below for definitions) as it pertains to the content of the presentation. Should it be determined that a conflict of interest exists as a result of a financial relationship you may have, you will be contacted and methods to resolve the conflict will be discussed with you. In addition, all affirmative disclosures must be revealed by a slide at the beginning of the presentation. Failure or refusal to disclose or the inability to resolve the identified conflict will result in the withdrawal of the invitation to participate.
  • List the names of proprietary entities producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this purpose we consider the relevant financial relationships of your spouse or partner that you are aware of to be yours.
  • Explain what you or your spouse/partner received (ex: salary, honorarium etc) and specify your role.
If your presentation describes the use of a device, product, or drug that is not FDA approved or the off-label use of an approved device, product, or drug or unapproved usage, it is your responsibility to disclose this information verbally to the learner during your presentation.
 
This author does not have any relevant financial relationships with commercial interests that pertain to the content of his/her presentation
 
This author does have relevant financial relationships with commercial interests that pertain to the content of his/her presentation
 
Commercial Interest Nature of Relevant Financial Relationship
(Include all those that apply)
What I or spouse/partner received My role
Example: Company X Honorarium Speaker
Please email PTS with your full disclosure statement if you have more than 5 disclosures to report.

What was received: Salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest, (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. My Role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities.

 
 
Pediatric Trauma Society
500 Cummings Center, Suite 4400, Beverly, MA 01915
Phone: 978-927-8330 | Fax: 978-524-0461