DEPARTMENT OF MEDICINE RESIDENT RESEARCH DAY 2024 ABSTRACT SUBMISSION FORM The Abstract Submission Deadline is Tuesday, April 2, 2024 at 11:59 pm EST. First name Last name Email Phone Supervisor Last name First name (Supervisor must hold a primary appointment in the Department of Medicine. If not, explain below) Supervisor's Email Supervisor's primary hospital/laboratory location in 2023 If your supervisor does not hold an appointment in the Department of Medicine, please provide us with additional information Resident (medical or non medical) PGY-1    PGY-2    PGY-3    PGY-4    PGY-5    PGY-6    PGY-7 MD Student MSc Student PhD Student Undergraduate Post-Doctoral Fellow Clinical Fellow Faculty Specific Subspecialty of Medicine -CardiologyCl Immunology and AllergyClinical PharmacologyCritical Care MedicineEndocrinology and MetabolismGastroenterologyGeneral Internal MedicineGeriatric MedicineHematologyInfectious DiseasesNephrologyRespirologyRheumatology Category Epidemiology Case Report/Series Genetics Medical Education RCT Pharmacology/Biochemistry/Molecular Biology Other Resident Research Specialty Awards (in addition to the regular Research Day awards) Please select the Research Specialty Award that applies to your abstract submission (if appropriate). Please refer to the Terms of Reference for the Research Specialty Awards. Eligibility will be confirmed by the division or QI team. I am eligible for the following Research Specialty Award(s) (please indicate all that apply) Geriatric Medicine General Internal Medicine Quality Improvement Have you presented this abstract at another meeting/conference? yes no If yes Where (city/country) Event (name of event) When (yyyy-mm-dd) Disclosure of Conflict of Interest Title of CPD activity Date of CPD activity What is your role in the CPD activity? Member of the scientific planning committee Moderator Speaker Author Facilitator Other I do not have a relationship with a for-profit and/or a not-for-profit organization to disclose I have a relationship with a for-profit and/or a not-for-profit organization to disclose Please indicate the organization(s) with which you have/had a relationship over the previous two years and briefly describe the nature of that relationship. Nature of relationship(s) Name of for-profit or not-for-profit organization(s) Description of relationship(s) Any direct financial payments including receipt of honoraria Membership on advisory boards or speakers' bureaus Funded grants or clinical trials Patents on a drug, product or device All other investments or relationships that could be seen by a reasonable, well-informed participant as having the potential to influence the content of the educational activity To be completed by speakers and authors only I intend to make therapeutic recommendations for medications that have not received regulatory approval (i.e. "off-label" use of medication). Note: You must declare all off-label use to the audience during your presentation. Yes No I acknowledge that the National Standard requires that any description of therapeutic options utilize generic names (or both generic and trade names) and not reflect exclusivity and branding. Yes No I Agree By clicking "I agree" you are acknowledging that the above information is accurate and that you understand that this information will be publicly available. Name: Date: Title First author Coauthors Abstract (Maximum 250 words) Word count: Note that all submitted abstracts will automatically be considered for DOM Resident Research Day awards in the appropriate categories. Please click here to see the list of award categories.