Innovation enquiry form

To ensure we provide you with the best support available, we kindly ask that you fill out our Innovation Enquiry Form. This will enable us to learn as much about you and your innovation so we can assist appropriately. Thank you in advance.

1. Prefix

2. First Name

3. Surname

4. Email

5. Office Phone Number

6. Mobile Phone Number

7. Organisation Name

8. Department

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9. Job Title

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10. Company number

11. LinkedIn

12. Twitter

13. Organisation Address

14. Town

15. County

16. Country

17. Postal Code

18. Sector

19. What is the title of your innovation?

20. What is the area of your innovation?

21. If ‘Other’ please specify the area of your innovation

22. What is the stage of your innovation?

23. If ‘Other’, at what stage is your innovation at?

24. Tell us more about what type of support you need from Life Sciences Hub Wales and how your innovation addresses an unmet need? (Feel free to share links or anything that might help to explain your enquiry)

25. Other support required?

26. Have you previously been in contact with anyone at Life Sciences Hub Wales?

27. If yes, please identify LSHW contact here

28. What is the Size of your Organisation (employees)?

29. What is the main purpose of your innovation?

30. What problem does your innovation solve and how does it do this?

31. What is the regulatory status of your innovation in the UK?

32. Other Regulations?

33. Will your innovation require interoperability with current NHS Wales Systems?

34. Does your innovation process data?

35. If yes, have you undertaken a Data protection impact Assessment?

36. Has your innovation completed a clinical trial?

37. Please describe details of the clinical trial and the outcome if applicable

38. Has your innovation gained real world validation within a Health or Social Care setting within the UK?

39. If applicable, please describe this evaluation and the outcome (including the setting name and address that this took place)

40. What population demographic or subgroup is this innovation intended for?

41. Which Clinical Specialty areas does the innovation impact on? Select no more than 4 options across questions 43-45

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43. Which Non-clinical specialty areas does the innovation impact on? Select no more than 4 options across questions 43-45

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44. Other Areas of impact?

45. In what setting will the innovation be used?

46. Do you know the current pathway that your innovation would sit within?

47. Please describe the current pathway with your innovation in use, including how patients would be identified

48. Approximately, how many people a year would benefit from your innovation?

49. How long is your innovation intended to be used for?

50. What are the PATIENT benefits for your innovation? Please choose up to 3

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51. What are the SYSTEM benefits of your innovation? Please choose up to 3

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52. Please describe how your innovation delivers and achieves the benefits for both the patient and the system in relation to the previous question in a qualitative and quantitative format

53. What are the costs associated with your innovation, compared to the innovations/ solutions that are currently in place?

54. Please describe your cost model

55. Is there any further information you would like to add in relation to your innovation? (e.g., academic papers, clinical study report, evaluation report, patient feedback, cost-effectiveness – include savings for the Health and Social Care systems and period of return on investment). Provide links to sources, case studies, published papers, expert opinion, independent evaluation (e.g., Health Technology Wales, NICE, etc.)

Innovation enquiry form

Part 2