University of Illinois College of Medicine at Peoria

Research Day Application

Research Day Application

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NOTE: If you submitted an abstract in 2020 and wish to present it at this year's event, please use this form instead.

1. Status of presenter

required

1. Status of presenter

Med Student

Resident

Nursing

Other

2. If other, please explain

3. Applicant full name

4. Email address

5. Mentor full name / Title

6. Mentor email address

Mentor must approve the submission in order for the application to be accepted. Mentors will be contacted for verification.

7. Approved by mentor?

required

7. Approved by mentor?

Mentor must approve the submission in order for the application to be accepted. Mentors will be contacted for verification.

Yes

No

8. Category

required

8. Category

Clinical Vignette

Research

CQI

9. IRB Approval

required

9. IRB Approval

Yes

No

Filed/Pending

10. IRB Approval # (if applicable)

11. Title of Abstract

12. Authors (list presenter first; separate authors with semicolon)

13. Upload abstract as a Word document. (All uploaded abstracts must include the applicant name and abstract title.) (maximum file size: 15MB)

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