APPLICATION FOR ANNUAL TRAINEE SYMPOSIUM

Submission Deadline: Wednesday, January 29, 2020, 4:00 p.m.

A.	Directions: ALL of the information requested must be supplied. This cover page and a one-page abstract must be submitted electronically (as a single MS Word file) to Kristi Katcher (kkatcher@siumed.edu) prior to the deadline. Follow directions: abstract is limited to one page. Provide a succinct title, list all authors and their department affiliations; structure abstract text according to instructions; 1” margins all around, Arial 11 font, with single spacing.

PRESENTOR:

Typed Name:	Signature/Initials:

STATUS (check one):

Resident	Graduate Student--MS
Clinical Fellow	Graduate Student—Ph.D.
Medical Student, List Year __________	Postdoctoral Fellow

PRIMARY DEPARTMENT (AND DIVISION, if appropriate):	Email (students must use @siumed.edu; others most used email)

TITLE OF PROJECT/PROPOSAL:

SCHOOL MAIL CODE & PHONE NUMBER:

TYPE OF ABSTRACT (Check one):

Original research (hypothesis-driven study)	Case study/clinical vignette

NAME OF PRIMARY MENTOR	DEPARTMENT:

A.

OTHER MENTORS:	DEPARTMENTS:

A.
B.
C.

Preferred Presentation Time:

a.m.	p.m.

This box MUST be checked for submission. Check box to attest:

Submission of this cover page and abstract affirms that first author, all co-authors and the responsible mentor: meet eligibility criteria for submission, have read and approve the content of the abstract and the authorship listing; approval of the project is explicitly granted by the responsible faculty member, and the first author will present the project.

12/4/19