INSTRUCTIONS: Fill out this application in its entirety. The application must be submitted as a single pdf document to the OTT via email (techtransfer@siumed.edu). Applicants are responsible for complying with all award requirements.

SECTION 1. APPLICANT INFORMATION. TO BE COMPLETED BY APPLICANT.

INSTRUCTIONS: Fill out the following section. The signature and date may be completed electronically. The information below represents a summary of the award requirements and terms. The entire description can be found at www.siumed.edu/adr/concept-development-award.html.

Signature	Date
Printed Name	Campus
Title	Department
Title/Subject of Invention

Award Goals and Scope

This award covers patentable inventions, trade secrets, and copyrightable material and is intended to stimulate interest in and involvement with the technology transfer process at SIUSM, assist in moving technologies into the market, and promote the economic welfare of the University and surrounding community. This award is intended to cover costs not met by other means, and may not be used to support applicant salaries, basic R & D, or work on new ideas. Total annual award money depends on the available overhead funds from the Office of the Associate Dean for Research. Each application may request up to $15,000. Disclosure of the invention to the Office of Technology Transfer (OTT) is a requirement for eligibility and must be done at least one month prior to the application submission deadline for a particular funding cycle. The award is given semi-annually, subject to availability of funds.

Eligibility

All current SIUSM employees with active inventions covered under the Intellectual Property Policy may apply (policy can be found at http://www.siumed.edu/adrfa/techtranspolicy.html).

Application Process and Procedures

Applicants must submit an electronic application to the OTT via email (techtransfer@siumed.edu) between 8:00 A.M. on the first Monday in October and 4:30 P.M. on the third Monday in October (Cycle A) or between 8:00 A.M. on the first Monday in February and 4:30 P.M. on the third Monday in February (Cycle B).

Selection Criteria

Criteria include value, well-conceived plan, intellectual property merit and scope of protection, market transferability, and business or legal consultations. Each application will be assigned a merit score and ranked using these criteria.

Selection Process and Procedures

Award recipients will be announced on the first Monday in December (Cycle A) and the first Monday in April (Cycle B). Each recipient will receive up to $15,000 per invention to be used within one calendar year. After one year, remaining funds will be returned to the Concept Development Award Fund and recipients will be required to submit a Progress Report (for due dates, please see the detailed award description).

SECTION 2. INSTITUTIONAL APPROVAL. FOR OFFICIAL USE ONLY.

_____ Disclosure requirements HAVE been met	_____ Disclosure requirements HAVE NOT been met

Signature of Director of Office of Technology Transfer	Date

SECTION 3. NARRATIVE. TO BE COMPLETED BY APPLICANT.

INSTRUCTIONS: Address each of the following subsections as completely as possible. The entire Narrative may not exceed 3 pages. None of the subsections may be deleted to create more space in this section.

3A.	INVENTION DESCRIPTION

Describe the invention and its current state of development. Trade secrets need not disclose the specific trade secret material, just a description of what it concerns. This section should give a clear, concise picture of the invention and the science behind it.

3B.	PROPOSED TIMELINE

Create a realistic timeline of the steps necessary to transfer the invention from its current state to the market. Identify and highlight the steps/milestones that will be carried out if this application is funded. Provide a general description of how the highlighted steps will be carried out, not a detailed “Materials & Methods” description.

3C.	OTT ACTIVITY

Provide the internal OTT file number(s) associated with this invention. Describe the extent of any discussions/ consultations with the OTT, including whether SIU-SOM has accepted responsibility for this invention. List any patent, patent application, copyright, or trademark number(s) and filing date(s) associated with this invention.

3D.	MARKET INFORMATION

Provide an assessment of the potential market size (use concrete numbers when possible) and the market viability. Indicate how the invention is beneficial or an improvement on existing technology.

3E.	BUSINESS/LEGAL DISCUSSIONS

Describe any additional discussions that either you or the OTT have been involved in, especially those relating to licensee interest. If the invention is associated with a start-up company, describe that relationship.

SECTION 4. OTHER SUPPORT. TO BE COMPLETED BY APPLICANT.

INSTRUCTIONS: Answer the questions provided. There is no page limit for this section.

QUESTION 1. Does the applicant have Other Support? (answer Yes or No) Other Support includes Federal, non-Federal, commercial, institutional, and other sources of funding support. If you answered NO, proceed to Section 5. If you answered YES, answer Questions 2 and 3 before proceeding to Section 5.
QUESTION 2. If Other Support exists, provide the following information for all sources of active and pending support for the last 3 years: Project Number (and Principal Investigator), Source of Funding, Annual Budget (Direct Costs), Project Dates, % Effort, Title, Specific Aims/Major Goals. Active Support: Pending Support:
QUESTION 3. If Other Support exists, summarize the overlap of the projects with the current application.

SECTION 5. BUDGET INFORMATION. TO BE COMPLETED BY APPLICANT.

INSTRUCTIONS: Fill in all requested information. There is no page limit for this section.

5A. ITEMIZED BUDGET

For Key Personnel, enter descriptive information and salary requested. Salary support for the applicant is not permitted. For all other categories, enter a description of the item(s)/service(s) being requested and an approximate purchase cost. Make sure to enter the total amount requested. Indirect costs are not allowed.

DESCRIPTION OF ITEM REQUESTED	DOLLAR AMOUNT REQUESTED (omit cents)
KEY PERSONNEL
NAME	ROLE ON PROJECT	% EFFORT	BASE SALARY	SALARY REQUESTED	FRINGE BENEFITS	TOTAL REQUESTED
•
•
•
SUBTOTAL:
CONSULTANT COSTS
SUBTOTAL:
EQUIPMENT ITEMIZE:
•
•
SUBTOTAL:
SUPPLIES ITEMIZE BY CATEGORY:
•
•
SUBTOTAL:
TRAVEL
SUBTOTAL:
OTHER COSTS ITEMIZE BY CATEGORY:
•
•
SUBTOTAL:
TOTAL COSTS

5B. BUDGET JUSTIFICATION

Provide a justification for key personnel associated with the application. For other items/services costing over $3,000, provide a detailed justification.

Key Personnel:

Consultant Costs:

Equipment:

Supplies:

Travel:

Other Costs:

SECTION 6. REFERENCES. TO BE COMPLETED BY APPLICANT.

INSTRUCTIONS: Provide full citations for all cited references. If there are no references in the application, state “No References.” This entire section may not exceed 1 page.

SECTION 7. APPENDIX. TO BE COMPLETED BY APPLICANT.

INSTRUCTIONS: Answer the following questions about the application to determine if an Appendix is needed.

QUESTION 1. Has this invention been funded through a previous funding cycle of the Concept Development Award? If you answered NO, your application is complete and no Appendix is required. If you answered YES, proceed and answer Questions 2 and 3.
QUESTION 2. What previous funding cycle funded this invention?
QUESTION 3. Have you already submitted a Progress Report for the funding cycle listed above? If you answered YES, attach a copy of the finalized, approved Progress Report as an Appendix** If you answered NO, fill out the Progress Report and attach it to this application as an Appendix**. **To attach an Appendix, first convert the Application and the Progress Report to pdf documents. Open the pdf application in Adobe Acrobat (not Adobe Reader), choose “Combine” from the main tasks bar, then select “Merge Files into a Single pdf.” Select the “Add Files” option, locate the Appendix pdf file, then select “Combine Files” and save the resulting pdf document for submission. This method will allow you to insert the Progress Report at the end of the application. Do not copy and paste content from the Progress Report into this space.