Institution:

Mailing Address:

Address (cont.):

City: State: Zip:

Country:

Email: Work Phone:

Cell Phone: Fax:

AACN Member: Yes No (membership not required)

Is first author a student, intern or resident: Yes No

1. Only indicate the abstract as a student abstract if the student (or fellow) is a FIRST author.
2. Submissions must include actual data, not data you plan to collect. Case studies are of course appropriate.
3. Please refer to the below posted example abstract regarding style issues including the use of capitalization and acronyms in the title. Acronyms are acceptable in the text of the abstract. Some acronyms of more universally recognized assessment measures, procedures or disorders are Ok to use in the title. In the text they should still be spelled out fully for first use. The following list of measures, disorders, and procedures are the only ones that should be presented as acronyms in the title: all versions of WAIS, WMS, CVLT, MMPI, and HIV, TBI, PTSD, MRI, CT. It is acceptable to spell these out if you prefer, but please DO NOT assume acronyms with which you are familiar are universally understood. All others should be spelled out in the title and the first time they are used in the text.
4. Please refrain from using section headers in the abstract (e.g., Methods, Results, etc.).
5. Do not include credentials in the authors listing.
6. Do not submit the same abstract twice – if you are unsure as to whether your submission went through, please wait it out then contact us directly if you remain unsure after 1-2 hours. Also, please check your spam/junkmail folder for the verification email.

Number of Authors: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

                 First Name  Middle Initial  Last Name

Title:

Abstract:

ABSTRACT CLASSIFICATION: Please rank the two content areas which best categorize your abstract. Select a 1 for the primary categorization and 2 for the secondary categorization.

1    2	1    2
Alzheimer's Disease	HIV/AIDS
Attention	Intellectual Functioning
Brain Tumors	Language Disorders
Cerebrovascular Disease	Learning Disabilities/ADHD
Cross Cultural Issues	Medical Disorders
Dementia/Aging	Memory
Demyelinating Disorders	Movement Disorders
Developmental	Neuroimaging
Epidemiology	Neuropsychological Testing
Epilepsy	Parkinson's Disease
Executive Functioning	Psychiatric Disorders
Forensic	Traumatic Brain Injury
Genetics	Visuospatial Functions
Other:

AUTHOR PERMISSION TO PUBLISH ABSTRACT:
Corresponding author must authorize AACN the right to publish your abstract in The Clinical Neuropsychologist (TCN). In consideration of AACN reviewing and editing this abstract submission, the author hereby transfers, assigns or otherwise conveys on behalf of all authors ownership of this abstract to AACN in the event that this abstract is published. The author warrants that this abstract is original and holds AACN harmless for any and all defects or claims arising from its publication. I AGREE

CONFLICT OF INTEREST DECLARATION:
Corresponding author must complete.
1.a. Will your presentation include any commercial products or services?
         Yes No (If No, skip to question 2)
1.b. If Yes, do you have a significant financial interest or other relationship with the manufacturer(s) of any of the products(s) or provider(s) of the products or services referenced in your presentation?
         Yes No (If No, skip to question 2)
     If Yes, please list the manufacturer(s) or provider(s) and describe the nature of the relationship(s):
    
2. Please list any and all sources of funding that supported the work described in your presentation:
    

Type OK in this box: (human verification)

UNDERSTANDING AND AGREEMENT:
I confirm that the information contained in this submission form is accurate. I understand and agree to the terms of this agreement.

AACN MEETING REGISTRATION INFORMATION: Corresponding authors must register for the meeting to be eligible to present their work. For questions, please contact Pamela McMurray via email: pamela.mcmurray@phci.org or by phone: 262-928-2652, or Gina Rehkemper via email: gina.rehkemper@phci.org or by phone: 262-928-7667.