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UCL INNOVATION & ENTERPRISE UCL’s HEIF Early stage commercialisation application 1. Project Info Project title Call Stream: HEIF - ESC Sub-stream: Early Stage Commercialisation Call: KEI2022(-XX) PI / academic lead Given Name Last Name at UCL UCL Email UPI Department Co-Investigators at UCL Name UCL Email Department UCL UPI Declaration of Interest Are you in compliance with UCL’s policy Please provide details as needed e.g. details of interest, on Disclosure of Conflicts and an explanation if your answer is ‘No’ Declaration of Interest? ☐ Yes ☐ No If relevant to this proposal, have you Please provide any further information if applicable disclosed any actual, potential or perceived conflicts of interest to UCL? ☐ Yes ☐ No Ethical Approval Do you require ethical approval for this project? ☐ Yes ☐ No Confidentiality ☐ Yes, my application contains confidential ☐ No, my application does not contain confidential information that should not be shared publicly information that should not be shared publicly Please provide details: 2. Partner Organisation(s) (if any) Name 1 UCL INNOVATION & ENTERPRISE Organisation type ☐ Public – Central Government ☐ Private – Community Interest ☐ Public – Local Government Company (CIC) ☐ Public – NGO ☐ Charity or Trustee Managed ☐ Private – Public Limited ☐ Social Enterprise Company (PLC) ☐ Higher Education Institution ☐ Private – Limited Company (Ltd) ☐ Research Institute ☐ Private – Limited Liability ☐ Funding Body Partnership (LLP) ☐ Other (please specify) Size of company ☐ Micro ☐ SME ☐ Large ☐ Large multinational Lead contact Name Email Job title Business phone number Address Sectors ☐ Aerospace, Defence, ☐ Environment (select up to 2) Marine ☐ Financial Services & Management ☐ Agriculture, Food, Drink Consultancy ☐ Chemicals ☐ Government, Democracy and Justice ☐ Communities and Social ☐ Healthcare Services/Policy ☐ Leisure, incl. sports, recreation & tourism ☐ Construction ☐ Manufacturing, incl. Industrial ☐ Creative Economy Biotechnology ☐ Culture, Heritage, Museums ☐ Pharmaceuticals and Medical and Collections Biotechnology ☐ Digital/Comms/Info Tech ☐ Retail ☐ Security, Diplomacy ☐ Education ☐ Transport ☐ Electronics ☐ Other (please specify) ☐ Energy Is this the first time you have ☐ Yes ☐ No ☐ Don’t know worked with this partner? Details of previous engagement 3. Planned Activities Summary of aims and objectives of the project: Describe fully the activities to be undertaken and how they will increase the impact of the underpinning research Describe the role of the partner organisation(s) (if any) 4. Impact and risk assessment How does this project fit in with the Innovation & Enterprise’s Strategy for 2021-23? 2 UCL INNOVATION & ENTERPRISE Provide an outline of why this project matters in ‘real world’ terms: Describe (i) anticipated outcomes, (ii) the potential impact and beneficiaries, (iii) measures of success: Plan for ongoing activity and securing further funding if project is successful Risk assessment and competitor analysis: Commercialisation possibilities, including UCLB engagement: UCLB Business Manager: 5. Track Record Summary of Summary: underpinning work and link to grant portfolio Project numbers: Research Council grant(s) Other Outline of your Summary: previous engagement in Project numbers & year received: knowledge exchange or UCL HEIF External Other UCL innovation 6. Resources and Financial Details Proposed start Proposed end Partner Details of contribution from partner organisation: contribution (if any) Cash (£) In kind (£) Total (£) UCL funding Staffing and recruitment requirements: requested (£, direct costs only) Justification of resources requested: Salaries Consumables Travel Other Total List expected spend by month: 3 UCL INNOVATION & ENTERPRISE Funding request per financial year (1st Aug–31st July): Financial Year 1 Financial Year 2 Financial Year 1 Value (£) Financial Year 2 Value (£) Funded staff details Name FTE (insert more copies of this section if needed) UCL background ☐ Doctoral student ☐ Postdoctoral staff ☐ Teaching ☐ Other academic staff ☐ Technical/support ☐ Other (please specify) Date from Date to Departmental Given Name: Manager or Last Name: Departmental Email: Administrator with budgetary Department: responsibility UPI: Worktribe ID MyFinance Organisational Unit 7. Completion & Documents Confirm Documents attached 1. Standalone Worktribe costings (Excel) 2. Costing spreadsheet 3. Evidence of Partner Organisation support (i.e., letter or email of support) Head of Department Head of Given Name Last Name Department UCL Email UPI Department 4
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