2018 Calls for Abstracts - Financial Disclosure Survey

This survey applies to all abstracts submitted for potential presentation at one or more of the following: Evidence-Based Spine Interventions Seminar (February 3-4, 2018 - Bonita Springs, Florida); 2018 European Congress (23-25 March 2018 - London); 26th Annual Scientific Meeting (August 15-18, 2018 - Chicago).

If you are submitting abstracts for multiple meetings during the year, you only need to complete this survey ONCE, unless your information has changed since the previous date of completion.

Visit the SIS Call for Abstracts webpage for more information, formatting requirements, and the online submission forms.

All authors of an abstract are required to submit a disclosure. Potential for conflict of interest can exist whether or not the Discloser believes that the relationship affects his or her judgment.

This disclosure form is intended to supplement, but not replace, any applicable state laws governing conflicts of interest applicable to non-profit and charitable corporations.

Disclosers must disclose all personal financial interests, affiliations, and relationships, including those of family members (spouse, domestic partner, parent, child, and sibling) that may be perceived as potentially influencing the grantee or research implementation or board, division, committee, or task force activities. Conflicts of interest pertain to, without limitation, subject matter that has a reasonable potential to result in financial, professional, or other personal gain or loss for the Discloser, the Discloser’s family, employer, or other persons with whom the Discloser maintains a relationship.

If any changes occur to the disclosed information after the form is submitted, a new/updated form must be submitted to SIS immediately.

The Research Division will review your disclosures as part of abstract evaluation.

For more information, please see the Society's Disclosure Policy on the SIS website http://www.spineintervention.org/?page=disclosure_policy

Question Title

* 1. Please provide your name details:

First Name:

Last Name:

Credentials:

Question Title

* 2. Please tell us how you would like your name listed on the SIS website and any printed materials. (Example: Patty/Pat Smith, MD vs. Patricia/Patrick Smith, MD):