2025 Eastern States Conference: Grid

First Name*

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Last Name*

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Email*

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Group* If you're unsure what group you're in please see the participating organizations list on our website, easternstates.org. If you cannot find your program in the participating organizations list talk to your program director or email easternstatesconf@gmail.com.

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Program* Program/Organization you are associated with.

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State* What state is your program in?

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Category*

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Registration Type* I am a...

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Presentation Type* PGY1s presents slide presentations. PGY2s present posters, unless otherwise specified by your RPD.

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Abstract Title

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Poster Competition If you are a PGY2 presenting a poster, would you like to participate in the poster competition?

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Evaluator* I understand as a Preceptor, RPD, PGY2, or Fellow that I will be scheduled to evaluate any given session during my group's scheduled days.

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Dietary Restrictions We will provide a list of dietary restrictions to our event coordinator at Hershey Lodge. However, it is the responsibility of the attendee to let a server know you are on the dietary restrictions list and need a meal from the kitchen.

Vegetarian

Vegan

Kosher

Gluten Free

No dietary restrictions

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Disclosure: Have you (or your spouse/partner) had a personal financial relationship in the past 12 months with the manufacturer of the products or services that will be discussed in this continuing education activity?* According to ACPE guidelines, we must collect a financial disclosure from everyone attending the Eastern States Conference--presenters and evaluators. Since everyone registering will be scheduled to either present or evaluate, you must complete the sections below.

Required

Resolution of Conflict of Interest* Please indicate below how the conflict of interest will be resolved.

I will support my lecture with the “best available evidence” from the literature

I will refrain from making recommendations regarding products or services

I will recommend an alternative speaker

I will divest myself of the financial relationship

N/A. There is no conflict of interest.

Required

Off-label or Investigational Use of Medications or Devices* I plan to discuss off label or investigational use of medications or devices in this program.

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Copyright* I have adhered to Copyright Law as it pertains to educational programs for all information obtained from other sources, to the best of my knowledge, in preparing my presentation and/or instructional materials.

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Signature*

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