Massachusetts-Israel Innovation Partnership (MIIP)

Grant Solicitation -- Health IT Track

(Solicitation No. 2014-MIIP-01)

Attachment B

Bilateral Collaboration Application Form Bilateral Collaboration Application Form

Instructions: Both partners applying for the program should fill this form in together and submit it to the two counterpart agencies. Please include resumes/CVs of key personnel.

1. General Information

1.1 Project Title (Do not exceed 120 characters)

1.2 Submission Date

1.3 Summary (Do not exceed 240 characters)

Healthcare IT(Select a subsector if applicable) Electronic Health Record Health Data Analytics Patient Safety Mobile Health Medical Imaging Public health Telehealth

1.5 Participants’ Contributions

Company Name Country Role of Participant Contribution (%) Budget ($US) Duration (Months)

Total:

1.6 Proposed Project Duration: ______months

Start Date: End Date:

1.7 Amount of Funding Requested

Proposed project budget(US$) Massachusetts company US$ Israeli company US$ Total project budget US$

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Proposed grant request (US$) (must Massachusetts company US$ be less than 50% of total project Israeli company US$ budget) Total grant request US$

Prior to the notice of this  No solicitation, did the two  Yes, If Yes, please describe companies listed below have any type of commercial or legal relationship?

2. Project Outline

2.1 Project Description: Please provide a high level description of the project

(Do not exceed 500 words)

2.2 Technological Development Envisaged (Level of Innovation)

2.3 Market Potential and Commercialization Plan (Please show the size of the market and establish the need for the product or process as well as the ability to secure any needed financing)

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2.4 Cooperation between Participants (Synergies, advantages, complementarities, etc.)

2.5 Expected Outcome of Project (Please show the anticipated economic benefits to Massachusetts: jobs created, additional revenues earned by the Massachusetts company, value of additional purchased inputs from Massachusetts suppliers, etc.)

2.6 IP Ownership Agreement

Please provide a summary here with a more detailed description to be included in the Draft Cooperation Agreement.

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3. Project Participants – Partner 1 (Massachusetts Company) 3.1. Participant Profile 3.1.1 General Profile Legal Name of Company DUNS # Tax Id #

Prior name of Company

Legal structure Corporation Limited liability company Partnership Sole proprietorship Stage Seed R&D Initial Revenues Revenue Growth

Ownership Public Private Governmental Other

Year Established No. Employees

No. R&D Personnel

Is the company domiciled in Massachusetts? Yes No, -> If No, please specify where the company is domiciled:

3.1.2 Company Contact Info Street Address

City P.O. Box

Country Zip Code

Telephone Fax

Website E-mail

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3.1.3 Contact Person First Name Last Name

Title Function

Phone Mobile Phone

3.1.4 Organization Background General Business Description & Area of Expertise (Include year that company was established and description of the nature and size of existing operations in each state/country where the company is doing business)

Technology Description (Include description of Primary Markets and Products/Services)

Targeted Customers

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Sales (for last 3 years) Current year (i) i-1 i-2

Annual revenue 2012 US$

2011 US$

2010 US$

Is/was the company 2012  Yes profitable?  No

2011  Yes

 No

2010  Yes

 No

Number of Massachusetts employees Israel

Other locations

Total employees

Number of R&D Massachusetts employees Israel

Other locations

Total R&D employees

Comments

3.1.5 Technology Sector & Subsector of Company (Select a subsector if applicable)

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Healthcare IT Electronic Health Record Health Data Analytics Patient Safety Mobile Health Medical Imaging Public health Telehealth

3.2 Work – Description and Contributions to the Project

3.3 Work Plan and Timeline

3.4 Budget and Resources

3.5 Other Sources of Financial Support Related to Proposed Research

3.5.1 Is this, or related R&D, presently being supported by other sources? If yes, indicate other sources, amounts, and dates of performing the R&D under this support

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3.5.2 Has your company previously received other sources of governmental support? If yes, list up sources and dates.

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4. Project Participants – Partner 2 (Israeli Company) 4.1. Participant Profile 4.1.1 General Profile Legal Name of Company Registration #

Prior name of Company

Legal structure Corporation Limited liability company Partnership Sole proprietorship

Stage Seed R&D Initial Revenues Revenue Growth

Ownership Public Private Governmental Other

Year Established No. Employees

No. R&D Personnel

4.1.2 Company Contact Info Street Address

City P.O. Box

Country Postal Code

Telephone Fax

Website E-mail

4.1.3 Contact Person First Name Last Name

Title Function

Phone Mobile Phone

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4.1.4 Organization Background General Business Description & Area of Expertise (Include year that company was established and description of the nature and size of existing operations in each state/country where the company is doing business)

Technology Description (Include description of Primary Markets and Main Products/Services)

Targeted Customers

Sales (for last 3 years) Current year (i) i-1 i-2

2012 US$ Annual Revenue 2011 US$ 2010 US$  Yes 2012  No  Yes Is/was the company profitable? 2011  No  Yes 2010  No Massachusetts Israel Number of employees Other Locations Total Employees

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Massachusetts Israel Number of R&D employees Other Locations Total R&D Employees

Comments

4.1.5 Technology Sector & Subsector of Company (Select a subsector if applicable) Healthcare IT

Electronic Health Record Health Data Analytics Patient Safety Mobile Health Medical Imaging Public health Telehealth

4.2 Work – Description and Contributions to the Project

4.3 Work Plan and Timeline

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4.4 Budget and Resources

4.5 Other Sources of Financial Support Related to Proposed Research

4.5.1 Is this, or related R&D, presently being supported by other sources? If yes, indicate other sources, amounts, and dates of performing the R&D under this support

4.5.2 Has your company previously received other sources of governmental support? If yes, list up sources and dates.

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5. Statement of Cooperation

The participants signing this form intend to cooperate within the project as described in this form with the aim of realizing the technical developments as set forth in Section 2. In addition the participants have or intend to, put in place a formal collaboration agreement. 5.1 Signature of Partner 1 Company Name

First Name Last Name

Title Function

Signature

5.2 Signature of Partner 2 Company Name

First Name Last Name

Title Function

Signature

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