2017 Mini-Seminar Submission form Moderator/Primary ContactName* First Last Degree Institution, City and State of the ModeratorEmail*Phone*Moderator Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country ASPO Membership*Please identify your membership status with the American Society of Pediatric OtolaryngologyYes, I am a MemberNo, I am not a MemberMini-Seminar PanelIdentify up to four (4) Panelists. *Please note that travel honoraria will not be offered.Panelist #1 Name First Last Degree EmailPhonePanelist #2 Name First Last Degree EmailPhonePanelist #3 Name First Last Degree EmailPhonePanelist #4 Name First Last Suffix EmailPhoneAbstract InformationThe Program Committee has included the following list of preferred topics for 2017 submissions. Greater preference will be given to submissions which fall into the topics listed below, however additional submissions will be accepted. • Evaluation of Common Medical Conditions • Newly Published Quality Improvement Guidelines on Otitis Media with Effusion • Newly Published Treatment Guidelines of Thyroid Carcinoma • Standard Surgical Procedures With Potential Long-Term ComplicationsTitle of Mini-Seminar (150 character limit)*Abstract Instructions*A good quality panel is one which: • Discusses an issue in detail • Presents two sides of a current issue, or • Debates new ideas for disease processes or new treatment regimens. Do not include the name of the author(s), institutions, pharmaceutical companies, or specific manufacturers on the abstract. Please insert your abstract (350 words maximum) below in black, single-spaced, 12 pt., Times New Roman font - (DO NOT include charts, graphs, or photographs.) Use initial caps only in title. Please split your abstract into the following four groupings in bold and all capitals: 1) INTRODUCTION 2) METHODS 3) RESULTS 4) DISCUSSION and CONCLUSION Abstract Learning ObjectivesThese objectives focus participant’s attention on the expected outcome of your presentation. • You should state clearly and succinctly what attendees can expect to learn from the mini-seminar. • Begin each statement as if it was preceded by “Upon completion of this session, participants should”. • Follow a numbered structure, starting with a verb (ie., Learn, Understand, Be able to, etc.). • We recommend that your submission contains at least two objectives.Learning ObjectivesKeywordsPlease provide 3 to 6 keywords.Keyword 1*Keyword 2*Keyword 3*Keyword 4Keyword 5Keyword 6Disclosure of Relevant Financial RelationshipsThe Speaker Disclosure Form is available here In accordance with the ACCME regulations, a disclosure form must be completed for each program participant and uploaded into the fields below. University of Colorado School of Medicine Disclosure Policy: The University of Colorado School of Medicine (UCSM) requires that a rigorous behavioral and educational performance needs assessment is the driver of the content and the educational method, ensuring that the scientific content is evidence-based. UCSM recognizes that to ensure transparency of financial relationships and eliminate commercial bias in CME activities, anyone who is in a position to control content of a CME activity (such as planners, faculty, authors and reviewers of CME) must disclose to OCME&PD a financial relationship with a commercial interest relevant to the proposed CME activity. The OCME&PD uses the mechanisms described below to identify and resolve all conflicts of interest prior to the CME activity taking place. If an individual who is in a position to control content of CME refuses to disclose relevant financial relationships to the OCME&PD, he/she will automatically be disqualified from any role in planning, management, presentation or evaluation of that CME activity. Commercial interests cannot take the role of a non-accredited provider in joint providership activities. Employees of commercial interests cannot be on the planning committee.Moderator Financial DisclosurePresenter #1 Financial DisclosurePresenter #2 Financial DisclosurePresenter #3 Financial DisclosurePresenter #4 Financial DisclosureDuplicate Submission: By checking this box I certify that this panel has not been presented at another meeting in the last two (2) years.