Salutation
First Name
Last Name
Company
Company Registration No.:
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City
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Parent Company:
Organisation Size:
Organisation Type:
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Other Category:
Innovation Name:
Problem Being Addressed:
Market Research Undertaken:
Brief Description of Innovation:
Product or Service?:
Innovation Type:
Similar or Equivalent?:
Innovation Differenciation:
Accessibility & Impact:
Negative Impact Assessment:
Environmental Benefit?:
Environmental Benefits:
Expected Benefits - Patients:
Expected Benefits - Healthcare Systems:
Expected Benefits - Economic Growth:
Expected Benefits - Over Existing:
Cost of Innovation:
Cost of Deployment:
Other Lifetime Costs:
Progress to Date:
External Funding / Support:
Initial Idea:
Intellectual Property Protected:
Proof of Concept Tested:
Early Prototype:
Working Prototype / Pathway:
Evaluation / Clinical Trial / Pilot:
Implemented in Single Site:
Spread Beyond Initial Site:
Other Status:
Innovation Impact:
Innovation Impact (Other):
Non-clinical Specialty Areas:
Non-clinical Other:
Primary Care Setting:
Other Care Setting(s):
Primary Theme:
Eligible Patient Population:
Already Implemented?:
Current Evidence:
Other AHSNs:
AHSN Contacts:
Other NHS Discussions:
Future AHSNs:
Future Plans:
Support Required:
Other Support Required:
Additional Information:
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