Principal Presenter Information
* Required Field
First Name *
Family Name *
Mailing Address *
State / Province
District Of Columbia
Prince Edward Island
(please select a country)
Antigua and Barbuda
Bosnia and Herzegowina
British Indian Ocean Territory
Central African Republic
Cocos (Keeling) Islands
Congo, the Democratic Republic of the
Falkland Islands (Malvinas)
French Southern Territories
Heard and Mc Donald Islands
Holy See (Vatican City State)
Iran (Islamic Republic of)
Korea, Democratic People's Republic of
Korea, Republic of
Lao People's Democratic Republic
Libyan Arab Jamahiriya
Macedonia, The Former Yugoslav Republic of
Micronesia, Federated States of
Moldova, Republic of
Northern Mariana Islands
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Slovakia (Slovak Republic)
South Georgia and the South Sandwich Islands
St. Pierre and Miquelon
Svalbard and Jan Mayen Islands
Syrian Arab Republic
Taiwan, Province of China
Tanzania, United Republic of
Trinidad and Tobago
Turks and Caicos Islands
United Arab Emirates
United States Minor Outlying Islands
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
area code, prefix, number
Preferred Email *
area code, prefix, number Institution *
Authors should be listed in the proper order. Full name(s) of the institution(s) is required.
Category & Title
If your abstract requires the use of a special character, you may use
the page linked here > to copy and paste the character where it is needed in your submission.
(Maximum characters: 2200)
Please provide three keywords
(separate by commas)
Conflict of Interest
CONFLICT OF INTEREST DISCLOSURE POLICY. Submissions must include completed Conflict of Interest (COI) forms from all co-authors. The submitting author's COI form must be completed as part of this online abstract submission. The form for all other co-authors is available online at: Acceptance of your abstract submission is contingent upon receipt of completed COI from ALL authors/presenters. Directions for submitting the additional COI forms will be included in an email you will receive once your abstract submission is completed. http://www.siumed.edu/cme/alzheimer/coiform.html COI forms from all co-authors must be submitted within 2 weeks of this abstract submission. Please do not submit the abstract more than once.
* Please choose one:
I am the only author
I will be providing COI for Co-Authors
Faculty or Planning Role:
Scientific Advisory Committee
The purpose of this form is to identify and resolve all potential conflicts of interests that arise from financial relationships with any commercial or proprietary entity that produces healthcare-related products and/or services relevant to the content you are planning, developing, or presenting for this activity. This includes any financial relationships within the last twelve months, as well as known financial relationships of your spouse or partner.
Please Choose One:
I have no financial relationship with a commercial entity producing health-care related products and/or services.
The commercial entities with which I have relationships do not produce health-care related products or services relevant to the content I am planning, developing or presenting for this activity.
I disclose the following financial relationships with commercial entities that produce healthcare-related products or services relevant to the content I am planning, developing or presenting:
Type of Relationship*
Content Area (if applicable)
*Type of relationship may include: full-time or part-time employee, independent contractor, consultant, research or other grand recipient, paid speaker or teacher, membership on advisory committees or review panels, ownership interest (product royalty/licensing fees, owning stocks, shares, etc) or any other financial relationship.
Please indicate your understanding of and willingness to comply with each statement below. If you have any questions regarding your ability to comply, please contact the activity coordinator as soon as possible.
I have disclosed to SIU School of Medicine all relevant financial relationships, and I will disclose this information to learners verbally (for live activities) and in print.
The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of a commercial interest. Content for this activity, including any presentation of therapeutic options, will be well-balanced, evidence-based and unbiased.
I have not and will not accept any honoraria, additional payments or reimbursements beyond that which has been agreed upon directly with the SIU School of Medicine.
I understand that SIU School of Medicine may need to review my presentation and/or content prior to the activity, and I will provide educational content and resources in advance as requested.
If I am presenting at a live event, I understand that a CME monitor will be attending the event to ensure that my presentation is educational, and not promotional, in nature.
If I am providing recommendations involving clinical medicine, they will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported or used in CME in support of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection and analysis.
If I am discussing specific healthcare products or services, I will use generic names to the extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.
If I am discussing any product use that is off label, I will disclose that that use or indication in question is not currently approved by the FDA for labeling or advertising.
If I have been trained or utilized by a commercial entity or its agent as a speaker (e.g., speaker’s bureau) for any commercial interest, the promotional aspects of that presentation will not be included in any way with this activity.
If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principles and methods, and will not promote the commercial interest of the funding company.