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11th Annual Scientific Meeting Abstract Submission Form
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Fellow/PiT Scholarship Information
At the time of abstract submission, the submitting investigator must identify if a fellow or physician in training will be presenting the abstract if it is selected. The abstracts will be evaluated and scored by the standard policy. If abstracts submitted by fellow or physicians in training are selected for either a podium or a poster presentation, scholarships may be awarded to them as follows:
Full ASDIN Meeting Scholarship: 1. If selected for podium presentation, up to two fellows or physicians in training will be awarded a Full ASDIN Meeting Scholarship which includes: Complimentary Meeting registration for the presenting fellow or physician in training Complimentary hotel accommodations for two nights for the presenting physician in training 2. If more than 2 fellows or physicians in training have been selected for podium presentation, the two fellow or physician in training abstracts with the highest scores will receive the Full ASDIN Meeting Scholarship.
Partial ASDIN Meeting Scholarship: Includes a 50% reduction of Meeting registration awarded in the following order: 1. Fellows or physicians in training selected for podium presentation who did not receive the full scholarship 2. The top 5 fellows or physicians in training selected for abstract poster presentation 3. Fellows or physicians in training that live in the same State as the hosting city
**NOTE: A maximum of 2 Full Scholarships and 5 Partial Scholarships will be awarded per year.

If Fellow/PiT will make abstract presentation, please indicate the name of the Fellow/Physician in Training to be considered for scholarship (if different from primary author) in form below. 

Conflict of Interest Disclosure
All authors must provide a complete conflict of Interest Disclosure.  Please, in submission form below, list Commercial Interest and Nature of Relevant Financial Relationship including Company Name and specifics of Financial Relationship (Employee, Grants/Research Support recipient, Board member, Advisor or Review Panel member, Consultant, Independent Contractor, Stock Shareholder, Speakers' Bureau, Honorarium recipient, Royalty recipient, Holder of Intellectual Property Rights, or Other)

All authors must consent to the following statements:

Publication Statement
As Primary Author, if accepted, I agree to provide the above-mentioned presentation either as a poster or an oral presentation or both based upon the wishes of the selection committee. I hereby give permission for publication of this abstract in the conference program and Journal of Vascular Access. I understand that presentation at this meeting does not preclude submission of the abstract elsewhere.

Compliance Statement
As primary author, I will uphold academic standards to ensure balance, independence, objectivity, and scientific rigor in my role in the planning, development, or presentation of this abstract. I agree to comply with the requirements to protect health information under the Health Insurance Portability & Accountability Act of 1996 (HIPAA).


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