Concept Development Award Application
For OTT Use Only:
Application Number
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 http://www.siumed.edu/adrfa/cdaward.html.
Signature
Date
Printed Name
Campus
Rank or 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 and Faculty Affairs. 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.
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
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Date
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Concept Development Award Application
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.
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Concept Development Award Application
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.
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Concept Development Award 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
TOTAL
NAME
ROLE ON PROJECT
% EFFORT
BASE
SALARY
SALARY
REQUESTED
FRINGE
BENEFITS
REQUESTED
•
•
•
SUBTOTAL:
CONSULTANT COSTS
SUBTOTAL:
EQUIPMENT
ITEMIZE:
•
•
SUBTOTAL:
SUPPLIES
ITEMIZE BY CATEGORY:
•
•
SUBTOTAL:
TRAVEL
SUBTOTAL:
OTHER COSTS
ITEMIZE BY CATEGORY:
•
•
SUBTOTAL:
TOTAL COSTS
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Concept Development Award Application
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:
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Concept Development Award Application
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.
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Concept Development Award Application
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.
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