APPLICATION FORM FOR THE AAGBI INNOVATION PRIZE

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APPLICATION FORM - AAGBI INNOVATION PRIZE FOR
ANAESTHESIA & CRITICAL CARE
Title and name:

Institution:

Mailing Address:

Contact Tel:

Email:


Title or keyword of innovation:

Does your innovation relate to:

               o Anaesthesia
               o Critical Care
               o Other area of medicine, please specify




Would you describe your innovation as:

               o   A new product
               o   An IT innovation
               o   A new technique or solution of a problem
               o   A sustainable environmental improvement
               o   Other, please specify (e.g. novel application)
Please provide a short description of your innovation (max 300 words),
specifying how and why it is innovative: what improvement it will make to
patient care and care including any problem/treatment challenge it will solve.
Please provide any references or supporting documentation you feel is
appropriate to your application




Are you the only individual claiming originality of this innovation?

              o Yes
              o No, please list other parties




Is your innovation protected in anyway from IP (Intellectual Property) point of
view? Have you obtained or applied for the following:

            o A patent
            o A registered design
            o A trademark
            o A copyright
            o Published in a peer reviewed journal
            o None of the above
            o Other protection, please specify




What stage is your innovation at:

            o Concept
            o Prototype
            o Produced, marketed and available
           o Other, please specify




What is your future vision for development of this innovation? Please indicate
any future support/funding you will need?




Thank you for your application for the Inaugural AAGBI Innovation Prize for
Anaesthesia and Critical Care. Please send completed applications to
secretariat@aagbi.org

The closing date for applications is 25 November 2011. The AAGBI will
confirm receipt of your application will be in touch in due course.

www.aagbi.org/innovation