Program Director Approval Page
DAGMEC Ninth Annual Resident Research Forum
 

Instructions:  This form should be completed by the resident/fellow and provided to their Program Director along with a copy of the abstract.  After the abstract has been approved, the Program Director should sign this form, indicating their approval of the submission.

This form should be submitted to DAGMEC by Thursday, April 10, 2008 at 5:00 p.m. via FAX:  937-228-1035

TO BE COMPLETED BY THE RESIDENT

Abstract Title:  _______________________________________________________________________

Resident’s Name (First-Author): _________________________________________________________

Residency Program Name: _____________________________________________________________

Other Authors:  ______________________________________________________________________

 PGY Level:  _____                    Check one:     ______Resident   ____ Fellow  

Please check type of project:  
_____  Research    or  _____ Education (case report, review, curricular material, etc.)

Mailing address: ____________________________________________________________________

Daytime pager number:   _____________________________________________________________

Please indicate which of the following research conditions apply to the proposed project. If your project has been reviewed and approved by the appropriate committees, note the dates.

human subjects:             Yes_____        No_____         Date approved_______________
animal subjects:             Yes_____        No_____         Date approved_______________
biohazards:                    Yes_____        No_____         Date approved_______________
radioisotopes:                 Yes_____        No_____         NRC Number ________________

TO BE COMPLETED BY THE PROGRAM DIRECTOR

I have reviewed the above named abstract and have approved it for submission to the DAGMEC Resident Research Forum. 

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Signature                                                                                                                 Date