Docstoc

Wellcome Trust

Document Sample
Wellcome Trust Powered By Docstoc
					               HEALTH INNOVATION CHALLENGE FUND

                              PRELIMINARY APPLICATION

This form must be completed in conjunction with the information for applicants available at:
                                   www.hicfund.org.uk

            Please complete the form using a font size no smaller than 10 point (Arial).


1. Project Title




2. Total Funding Requested (£)                                   3. Duration (months)




4. Lead Applicant’s Details

Surname
Forename(s)
Title
Position
Employing organisation
Address
Telephone

Email


5. Commercial Lead or Technology Transfer Officer’s Details

Surname
Forename(s)
Position
Employing organisation
Address
Telephone
Email



HICF Preliminary Application July 2009                                                Page 1 of 4
6. Summary

Please provide a summary of the proposal, identifying a) the healthcare need to be addressed, b)
the technology to be developed to address this need, c) the advantage of this technology over
existing approaches, and d) its potential impact on healthcare. (Max 200 words).




7. Background

Please describe the background to the proposed project, including: a) the unmet healthcare need;
b) the importance of the proposed work, including its relevance to the priorities and needs of the
NHS; c) an overview of existing technologies, and d) the potential advantages of the proposed
technology. (Max 500 words).




8. Current Status

Please describe the current stage of development of the technology. Describe any proof of
concept studies that have been conducted and any other data / evidence to validate your
technology. Please also outline the technical challenges to be addressed and overcome. (Max 500
words).




9. Details of Proposal

Please provide details of the proposed project (Max 4 pages):

9(a) Plan of Investigation: please detail the plan of investigation to be funded via the HICF,
including: the specific aims and objectives; at least two key milestones during the course of the
project




9(b) Project Management: please describe how the project will be managed to deliver the
milestones and key objectives




10. Potential Healthcare Benefits

Please describe the anticipated, outputs, outcomes and impacts on patients, ‘patient pathways’
and the NHS. (Max 500 words).




HICF Preliminary Application July 2009                                                     Page 2 of 4
11. Expertise and Experience

Please identify the key individuals who would take forward the project, if funded, summarising
their interests, expertise and track record in the relevant field(s). (Max 500 words).




12. IP and Commercial Matters

Please provide information in each of the following categories (Max 1000 words in total):

12(a) Innovative aspects: please describe the innovative aspects of your proposal or technology




12(b) Existing patents or applications: please provide details of existing patents or applications,
explaining how these relate to the proposal, also indicate the owners of the patent and publication
numbers (where appropriate)




12(c) Freedom to operate: please describe any freedom to operate issues that have been identified or
that might arise, explaining how these will be, or have been, addressed




12(d) Competitive Advantage: please provide a description of the competitive advantage of the
proposed technology over current approaches




12(e) Commercial strategy; please provide an explanation of why, at the end of HICF funding, the
technology will be attractive for follow-on investment or commercial exit, describing how this will be
achieved




13. Suggested Reviewers

Please provide names and contact details for three potential peer reviewers who have the relevant
expertise to provide appropriate peer review for your proposal, should it be invited to proceed to the
full application stage. These reviewers should be independent and have no conflict of interest with
respect to your application. Your suggestions will be used as only one source of peer reviewers and
may not be approached to undertake this review.

Reviewer 1

Surname

Forename(s)

Title

Institution


HICF Preliminary Application July 2009                                                      Page 3 of 4
Address

Telephone

Email

Expertise

Reviewer 2

Surname

Forename(s)

Title

Institution

Address

Telephone

Email

Expertise

Reviewer 3

Surname

Forename(s)

Title

Institution

Address

Telephone

Email

Expertise

14. Please indicate where you initially heard about the Health Innovation Challenge Fund
(pick one category)

Wellcome Trust/Dept of Health Staff Member   Presentation     Advertisement    Newsletter    Email
Wellcome Trust/ Dept of Health website Colleague    other (please specify below)




The completed form must be submitted, by email, to applications@hicfund.org.uk no later
than 5:00pm on Friday 2nd October, 2009. A hard copy of the application is not required.




HICF Preliminary Application July 2009                                                      Page 4 of 4