this is a test. More tests… Abstracts Corresponding Author Authors Presenting Author Poliquin Competition Senior Author Conflict Of Interest Name Abstract Title Preferred Presentation Type Podium Poster Poliquin Competition Is this submission to be considered for the Hodge Award or the Poliquin Competition? Yes, for the Hodge Award Yes, for the Poliquin Competition No If yes, please visit https://www.entcanada.org/fellowships-awards/awards-grants/hodge-memorial-award/ or https://www.entcanada.org/fellowships-awards/awards-grants/poliquin-resident-competition/ to view requirements / instructions. Most Relevant Subspecialty Otology/Neurotology Rhinology/Sinus Pediatric OHNS Head/Neck Endocrine Education FPRS General OHNS Laryngology Sleep Medicine Corresponding Author – Salutation Dr. Ms. Mrs. Mr. Corresponding Author – First Name Corresponding Author – Last Name Corresponding Author – Email Address * Corresponding Author – City Number of Authors 1 2 3 4 5 6 7 8 9 10 Author 1 – First Name Author 1 – Last Name Author 1 – Institution Author 2 – First Name Author 2 – Last Name Author 2 – Institution Author 3 – First Name Author 3 – Last Name Author 3 – Institution Author 4 – First Name Author 4 – Last Name Author 4 – Institution Author 5 – First Name Author 5 – Last Name Author 5 – Institution Author 6 – First Name Author 6 – Last Name Author 6 – Institution Author 7 – First Name Author 7 – Last Name Author 7 – Institution Author 8 – First Name Author 8 – Last Name Author 8 – Institution Author 9 – First Name Author 9 – Last Name Author 9 – Institution Author 10 – First Name Author 10 – Last Name Author 10 – Institution Is the presenting author a student, resident or fellow? Yes No If yes to the above, what is the name of the staff physician (meeting the criteria) that will be attending this presentation in the audience? Presenting Author – Last Name Presenting Author – First Name Presenting Author – City Presenting Author – Email Address * POLIQUIN COMPETITION ONLY - Would you like your abstract considered for the General Scientific Program if NOT accepted for the Poliquin Competition? Yes No POLIQUIN COMPETITION ONLY - The senior author must be registered for the meeting and present at the time of the presentation: Yes, I confirm this No, I do not confirm this POLIQUIN COMPETITION ONLY - Briefly describe the actual role of the resident in this research project. POLIQUIN COMPETITION ONLY - This is to verify that the Presenting Author (listed above) is the primary author for this paper which is to be considered for the Poliquin Resident Research Competition. I confirm that this submission contains proper and original research, the majority of which was completed by this candidate, and that it complies with all the rules and guidelines of the Poliquin Competition: I verify that the above is true. Do you have any special audiovisual requirements for your presentation? Yes No If yes, what would you need? Senior Author - First Name Senior Author - Last Name Senior Author - Email Address * Senior Author - City Abstract (Max 250 words) Learning Objectives Have you or the other authors made a presentation on behalf of a pharmaceutical or medical devices company in the last 2 years and / or have received financial compensation from said pharmaceutical or medical devices company? Yes No If yes, please provide details (financial interest / arrangement / affiliation with one or more organizations) Do you or the other authors have / had a financial interest / arrangement / affiliation with one or more organization(s). Yes No If yes, please provide details (financial interest / arrangement / affiliation with one or more organizations) Do you or the other authors have / had any financial interest / arrangement / affiliation with one or more organizations that could be perceived as real or apparent conflict of interest in the context of the subject of this presentation. Yes No If yes, please provide details (financial interest / arrangement / affiliation with one or more organizations)
