CaixaImpulse Form 2017 This Form has only an informative function. Applications will be submitted using the Application Form on the Programme s website (www.caixaimpulse.com). Paper applications or via any other channel will not be accepted. CaixaImpulse Form: Application details and Project Documentation 1
General Data Classification of the application Select the business area of your project Therapeutic Diagnostic Medical Devices Select the scientific area of your project Life Sciences Biomathematics Cell biology Human biology Biochemistry and Molecular biology Human physiology Genetics Immunology Microbiology Neurosciences Medical and Health Sciences Clinical sciences Epidemiology Forensic medicine Occupational medicine Internal medicine Nutritional sciences Pathology Pharmacodynamics Pharmacology Preventive medicine Psychiatry Public health Surgery Toxicology Classification of the applicant centre Select one of the following options University or university foundation Research and transfer centre (not university or hospital related) Technology centre Hospital or hospital foundation Non-profit organisation whose main activity is research Other CaixaImpulse Form: Application details and Project Documentation 2
General information about the project Abstract (proposal summary) The abstract should provide a brief description of the asset and its market potential, the value it brings to society and the specific objectives of the valorisation project. Information regarding the asset to be valued Protection status Patent/utility model not filed Patent pending Utility model pending Patent granted Utility model granted Estimated time-to-market Over 6 years Between 4 and 6 years Between 2 and 4 years Less than 2 years Brief description and level of development of the asset Description of the technology and its development history. Have experimental concept tests been carried out? Does an experimental or commercial prototype already exist? CaixaImpulse Form: Application details and Project Documentation 3
Project leader and team Project leader Project leader s knowledge and experience in the scientific field of the asset Describe the project s leader level of knowledge regarding the asset and/or technology. Describe the involvement of the project leader in the development of the asset. Project leader s knowledge and experience in the business/management field Describe the project leader s level of knowledge in the fields of business management, technology transfer and innovation management (1000 characters with spaces) Project leader s motivation and commitment What is the project leader's motivation regarding the valorisation and transfer project? Could the project leader be interested in continuing his/her involvement in the project once transferred to the market or for the possible start-up? What are his/her expectations regarding the programme? (1000 characters with spaces) Project team members details (if relevant) Team member 1 Include member Name and surname Job title, centre E-mail Profile, experience and dedication to the project (500 characters with spaces) Team member 2 Include member Name and surname Job title, centre E-mail Profile, experience and dedication to the project (500 characters with spaces) Team member 3 Include member Name and surname Job title, centre E-mail Profile, experience and dedication to the project (500 characters with spaces) Description of the team and the complementarities of the members expertise (max. 1000 characters with spaces) Only in cases where the participant has support personnel for the development of the valorisation project. Provide details of the team members, their profile and previous experience, dedication. If there is a support team, describe the profiles of the members (particularly if they have a technical, generalist, specialist or business profile) and their commitment to the project. If any requirements for other profiles to complement the team have been identified, describe them. CaixaImpulse Form: Application details and Project Documentation 4
Aims and activities Project objectives What are the specific project objectives? What indicators will be used to monitor the achievement of the objectives? This information allows the correct definition of objectives (specific, measurable, achievable, result-oriented, time-limited) and their alignment with the programme objectives (2000 characters with spaces) Valorisation actions Valorisation actions developed and results to date, valorisation actions estimated to be developed within the programme and indicative cost according to table provided under "Budget" section (2500 characters with spaces) Detail the valorisation actions that have been carried out and their results. Explicitly state if no valorisation action has been carried out. Estimate the valorisation actions necessary for the project; describe which are carried out within the programme framework. This estimated plan and the resources needed to its implementation will be developed during the first quarter of the programme. The overall approach and concretization efforts will be rated higher than specific actions. A detailed valorisation plan, if available, will be included as an attachment in the Documentation section. Transformation expectations for society Identification and description of consequences of transferring the asset to society. Contribution of the asset to improving people's quality of life, social progress and human development Ethical, social, legal and environmental project implications Describe the possible ethical, social, legal and environmental considerations related to the project and the transfer to the market: potential military use of the technology, use of human cells, embryos or human intervention in the research, third countries implication, possible impacts on the environment... Describe the ethics committee in the applicant centre (if existing) and describe the interest and willingness to introduce the project to it. CaixaImpulse Form: Application details and Project Documentation 5
Results and indicators Need or problem to be solved Description of the reasons behind the development of the asset and whether or not any of them respond to a social need. Describe the need or problem it addresses and the value it provides. (2500 characters with spaces) Level of innovation Describe whether the product represents an absolute novelty or if similar products already exist in the market. In case of the latter, identify and describe the existing products together with the improvements of the proposed solution compared to the existing product. (2500 characters with spaces) Beneficiaries and clients Economic and social benefits of the technology. Identification and quantitative estimation of potential direct and indirect beneficiaries of the solution. Identification of the client or potential clients. Estimation of the potential market size (national, international...). (2500 characters with spaces) Describe the benefits that the technology will provide from both business and social points of view: possible applications, economic and social impact, international impact... In case there is direct social applications indicate what it is and how society will benefit from the project. Initial identification and involvement of the different social agents Which people or groups of people are critical for the success of the project and could therefore have a positive or negative effect on the transfer to the market? Potential technological and strategic partners, subject matter experts, beneficiaries, potential clients... Based on the knowledge generated from the research, describe the level of involvement and influence of the different actors in society and their possible collaboration and participation (researchers, business people, policy makers and entities and civil society) CaixaImpulse Form: Application details and Project Documentation 6
Partnership Only in case of presentation in partnership with other entities Please specify the purpose of the collaboration for the partnership projects (400 characters with spaces) Please specify what contributions the partner entities will make for the project (amounts, concepts, etc) (400 characters with spaces) What benefits do you expect that the collaboration will have for the project? (400 characters with spaces) The amount requested is distributed within the partner members of the Consortium? Yes No In the case that the answer is yes, have you filled in the Requested Grant to la Caixa Foundation in case of distribution between the members of the Consortium template? Yes No CaixaImpulse Form: Application details and Project Documentation 7
Budget Concept Materials for experiments / R&D Outsourcing of activities for R&D development New recruitment of scientific personnel for the project Intellectual property protection Technical / scientific advice Requested grant to "la Caixa" Foundation Applicant centre contribution Partner entities contributions Other public and private contributions Contribution Entity name TOTAL PROJECT COST Business advice Legal advice Commercial and market analysis actions Regulatory development Production Design Prototyping Travel and accommodation expenses for the Project Leader (maximum 8.000 euros) Others Details CaixaImpulse Form: Application details and Project Documentation 8
Documentation Complementary documentation for project evaluation Patent or utility model application (mandatory if patent or utility model are filed). Related documents and studies (maximum 1 page). Letters of support or recommendation. 5 most important scientific publications ( advisable). Prototypes (maximum 1 page). Valorisation Plan (if available). Project leader's CV (maximum 1 page) (mandatory). Transfer Team Representative s CV (maximum 1 page) (mandatory). Other Project team members' CVs (mandatory if they exist) (maximum 1 page). Certification of data validation (available on the application) (mandatory) (Download template) Certificate from the Spanish Tax Agency assuring that the applicant centre has fulfilled its obligations with regard to taxation, valid at the moment of presentation of the project (mandatory). In case of a Portuguese entity it will be necessary a Declaration of a representative of the entity assuring that the applicant is in compliance with its local tax obligations (mandatory). Social Security certificate in force at the date of presentation of the project. Attach pdf or jpg. Certificate from the Spanish Social Security assuring that the applicant centre has fulfilled its obligations with regard to employment, valid at the moment of presentation of the project (mandatory). (mandatory). In case of a Portuguese entity it will be necessary a Declaration of a representative of the entity assuring that the applicant is in compliance with its local employment obligations (mandatory). Copy of the power of attorney certifying the capacity of the representative to act on behalf of the Beneficiary. (mandatory). In case of a Portuguese entity this document must be stamped with the Apostille of The Hague. (mandatory). Acceptance Letter duly signed (Download template) Requested Grant to la Caixa Foundation in case of distribution between the members of the Consortium (Download template) CaixaImpulse Form: Application details and Project Documentation 9