(Réservé aux organisateurs) Dossier n° 2017/
(Réservé aux organisateurs) Titre résumé: CONFIDENTIEL – DIFFUSION INTERDITE
APPLICATION FORM
You have developed an innovative product or project
helping to combat disability
You wish to submit an application for the
ISPRM/SOFMER INNOVATION CONTEST
PREAMBLE
You certify that the data submitted in this document are the result of your reflection and are not the property of a third party not mentioned as a partner of the project.
You acknowledge that the information transmitted will be reviewed by the contest organisers and is subject to confidentiality. This information will not be transmitted or disseminated to third parties without your consent and that no commercial use will be made of the data.
PROCEDURE
1. Send the application form before the 30th April 2018 deadline.
2. You will be sent confirmation of the admissibility of your application
3. Selected applicants will be invited to exhibit their project at a reduced rate in a dedicated area during ISPRM 2018
4. The Jury will review and select the winners during May 2018,
5. You will be informed of the results by the end of May 2018
6. The results of the contest will be announced during the closing ceremony of the ISPRM World Congress in Paris, on 12th July 2018.
PROJECT TITLE
Short title (<50 characters):
1. Actors in the project
1.1 Who is the main interlocutor?1
Name, given name of the project initiator 2:
Address:
Phone:
Mail:
Occupation:
Leading organisation 3:
Name:
Kind of organisation (company, lab, association…):
Head count:
Address, phone number, mail and website of the support organisation:
Other initiator(s) of the project:
NAME, given name and role in the project4:
1 If there are several project initiators, a representative of the group must be chosen.
2 join a CV at the end of the file
3 give a link for the presentation of the company/lab/association…
4 attach a CV for each person involved
1.2 Partners
Is the project driven by only one organisation or in a partnership
In case of partnership, provide for each partner:
NAME of the organisation 5:
Main role:
NAME, given name of the person responsible of the project for each organisation involved:
Address:
Phone: Mobile:
Mail:
Occupation:
5 give a link for the presentation of the company/lab/association…
2. The project
2.1 Summary (max. 500 words)
Name of the project:
Objectives of the project:
Rationale (scientific/economic/social):
Current state of development:
Developmentperspective: achieved phases and provisional timetable
Project cost – actual and future:
2.2 Project rationale: initial context, local opportunities, history, and progress up to this date (max. 1 page A4)
2.3 Detailed description of the project (max. 4 pages A4)
Clearly state if it is a product or a service;
Describe: 1 - the development and of deployment status; 2 - the innovative nature; 3 - the reliability and the feasibility; 4 - the trials conducted or in progress; 5 - the market analysis; 6 - the marketing perspectives; 7 - the economic valorisation solutions; 8- Partners involved or envisaged
Attach any file that you think useful.
3. Additional information
Does the project include a design dimension? YES NO
If so, explain why:
Does the project include a sustainable development dimension? YES NO
If so explain why:
Does the project concern human services? YES NO
If so, explain why:
Does the project concern social participation? YES NO
If so, explain why:
development assistance dimension
(for emerging countries)? YES NO
If so, explain why:
Does the project include an educational dimension for the person
or the caregiver? YES NO
If so, explain why:
Does the project is related with connected objects? YES NO
If so, explain why:
4. expected impacts of the project/device?
If you answer “yes”, explain why.
On the patient? YES NO
On the nursing and medical staff? YES NO
On the caregivers? YES NO
On the health organization? YES NO
On the social care model? YES NO
On care costs or benefit/cost ratio? YES NO
Other impacts? YES NO
5. What would you need for the development of your project?
5.1 Do you need financial support?
Please present the project budget, and any additional needs to complete your project
5.2 Do you need expert opinion and/or additional partners to complete your project?
Expert opinion/ partner in technical, scientific, clinic, experimental, economic or commercial areas
5.3 Do you need help in communications?
To increase the exposure of your project/device
6.For this project:
Are public aids requested? (If so, from which public organisation?)
Are public aids obtained? (if so, specify the origin and the amount)
Are bank loans requested or obtained? (if so, which bank(s) and which amount?)
Are prizes already won for this project? (if so, which prize)
7. Additional materials to be annexed below:
· You are required to provide the CV and links presenting the company/lab/association
· You can add figures, photos, links to videos or website links, patents or other document you consider relevan
______
Appendices:
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