Company Engagement Form

Section 1: Applicant Details

Title *
Forename *
Surname *
Telephone Number *
Email Address *
Website *
Name of the product (one product per application) *

Organisation *
Organisation Address Line 1 *
Organisation City *
Organisation County *
Organisation Country *
Organisation Postcode *

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Section 2a: Clinical Areas and Patient Benefit

Please provide a brief description of your product and why it is innovative (2000 characters max) *
Please indicate whether your innovation directly impacts onPatient outcomesEfficiency of clinical staffEfficiency of non-clinical staff or processes

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Section 2b: Innovation to Improve Patient Outcomes

e.g prevention, cure, avoiding harm

i) What is the clinicial problem that your product will solve? (2000 characters max)
ii) How many patients in England does this problem affect each year? (500 characters max)
iii) How will patients benefit as a result of your innovation? (1000 characters max)
iv) If your clinical benefits are supported by published third party research please provide the reference (500 characters max)

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Section 2c: Innovation to Improve Staff Efficiency

e.g. faster diagnosis, faster communication

i) What is the efficiency problem? (2000 characters max)
ii) How often does this occur in England each year? (500 characters max)
iii) How will your innovation improve efficiency? (1000 characters max)
iv) If your clinical efficiency improvements are supported by published third party research please provide the reference (500 characters max)
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Section 2d: Innovation to Improve Non-clinical Efficiency

e.g. improved staff morale, better patient experience, fewer missed appointments, reduced use of locum staff

i) What is the efficiency problem? (2000 characters max)
ii) How often does this occur in England each year? (500 characters max)
iii) How will your innovation improve efficiency? (1000 characters max)
iv) If your non-clinical efficiency improvements are supported by published third party research please provide the reference (500 characters max)

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Section 2e

i) Which of the clinical areas below does your innovation impact on? If you have selected staff or back-office efficiency gain in 2ai, please pick 'Generic' below BloodCancerCardiovascularCongenitalEarEyeInfectionInflammatoryInjuriesMental HealthMetabolicMusculoskeletalNeurologicalOral & GastroReproductionRespiratorySkinStrokeGenericUrology and IncontinenceOther:
ii) In what setting will your innovation be used? (Please tick all that apply HospitalPrimary CareCommunityCare HomePatients' HomesAmbulance or ParamedicHigh StreetWorkforce education and development

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Section 3: Your Business Case

Please give us an idea of how your innovation will be financially sustainable

a) Who will pay for your product or innovation?
b) If you can tell us what your product will cost, please do. If that's confidential, or not yet decided, please let us know.
c) Please estimate the direct clinical cost savings to the NHS that your product could achieve per year if fully implemented in England (800 characters)
d) If your answer to (c) is supported by independent economic analysis please let us know who did this (or mark as n/a if none available) (500 characters)
e) Please estimate, if possible, social care/other savings from your product per year if implemented in England (400 characters)
f) If your answer to 3e is supported by independent economic analysis please let us know who did this (or mark as n/a if none available) (500 characters)

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Section 6: Further Information

a) What do you consider is your next significant milestone (e.g. secure grant funding, recruit to clinical trial, obtain CE mark)? (400 characters)
b) What support are you hoping for?Research collaboration/clinical co-developmentHelp with clinical evaluationHelp with economic evaluation/building a business caseHelp with spread and adoptionSupport to obtain grant fundingOther:
c) Who are your competitors and why is your product better than their product/s? (300 characters)
Where did you find this form?Health Innovation SurgeryWessex AHSN and CRN Technology Support ProgrammeWessex AHSN 'Work with us' webpageOther

Section 1: Applicant Details

Section 2a: Clinical Areas and Patient Benefit

Section 2b: Innovation to Improve Patient Outcomes

Section 2c: Innovation to Improve Staff Efficiency

Section 2d: Innovation to Improve Non-clinical Efficiency

Section 2e

Section 3: Your Business Case

Section 4: Evidence, collaborations and funding

Section 5a: Innovation Readiness Levels

Section 5b: Is your Innovation ready for the Market?

Section 6: Further Information