Health Innovation Network - Innovator Engagement Form


About	Organisation	Innovation	Expected Benefits	Costs	Progress	Status	Engagement	Next Steps

About this form
- Please use this form to help us to understand your innovation, and your progress to date.
- Please do not disclose any unprotected intellectual property via this form.
- Data from this form will be used to assess whether, and how, we are able to support you.
- Your information may be shared across the Health Innovation Network.
- We will not share your information with other innovators or companies.
- You do not need to complete this form twice. If you’ve already completed it for any other Health Innovation Network please just tell us which one.
- Please see our Innovator Offer to find out more about what support the Health Innovation Network can provide.
Declaration - UK Sanctioned States

Prior to the completion of the Engagement Form the Health Innovation Network's are required to ask due diligence questions pertinent to the UK Government Sanctions List.
Is your organisation constituted or organised under the law of any UK Sanctioned State or Regime?

Please see here for more information.
*
N/A
Is your organisation owned or controlled by an entity based in a UK Sanctioned State or Regime? This may be a Parent Company or Person with significant control.

*
N/A
If you answer Yes to either question or are unsure, please provide further details below.
N/A

Summary of the innovation
Name of the innovation *
N/A

One innovation per application
Please can you tell us what problem you are addressing and how your innovation solves this?
N/A
Have you undertaken any market research to see if this fits with any NHS priorities? If so, please provide details
N/A
Brief description of the innovation, including intended purpose, functionality (how it works), clinical setting, and the opportunity (size of intended patient group)
N/A
Is the innovation a product or a service?
N/A
Innovation type
N/A
Describe any existing similar or equivalent technologies / products / services
N/A
How is your innovation, research project or request for help different to existing technologies / products / services?
N/A
Please explain how you have considered the accessibility and impact of your innovation on health inequalities, including any potential negative impact/s
N/A
If your innovation reduces health inequalities as defined within NHS England’s Core20PLUS5 approach, please tell us how (or enter N/A)

N/A
Does your innovation have an environmental and sustainability benefit in line with the NHS's net zero targets and ambitions (e.g. reduce journeys, consumable use, improved recycling, decarbonised supply-chain etc)? If so, please tell us briefly or mark as not applicable.

N/A

	Yes	No	In progress
Initial idea (Does your solution meet a specific health care challenge?) *
Intellectual property protected (Does your innovation have Intellectual Property or freedom to operate?) *
Proof of concept tested (Has your solution been validated?) *
Early protype (Has your innovation been developed?) *
Working prototype / pathway developed (Have you tested your innovation and considered where it fits into the current healthcare pathways?) *

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