MIT Sloan Healthcare Lab Fall 2015 Host Application Submission Deadline: Monday, August 10, 2015 Organization Information (* = required information) 1. Organization Name * 2. City and State 3. Street address 4. Zip Code 5. Website Primary Contact This should be the person whom the team can contact initially to discuss the project and with whom they will have most of their communication during the project. 6. Full name * 7. Job title 8. Primary Phone Number 9. Secondary Phone Number 10. Email address * 11. Skype account Secondary Contact This should be the person whom the team can contact if the primary contact is unavailable. 12. Full name 13. Job title 14. Phone number 15. Email address 16. Skype account Organization Profile 17. Describe which health or healthcare segment your organization is in (for example, hospital, pharma, technology, services, etc.). 18. When was your organization established? What stage is your company in: startup, expansion, established, or something else? 19. How many employees do you have? 20. Please describe the function of your unit, division, department. (For example, surgical services, medical records, product development, etc.) 21. How does your company fund its operations? (For example: self-funding from operations, angel funding or venture capital investment, etc.) 22. Do you have any links to H-Lab or MIT? Have you hosted an MIT Action Learning Lab team previously (welcome back!)? Do you have MIT Alumni working with you? Project In framing your project, please think of the H-Lab team as working on a short but intensive internship with your organization. The team will undertake significant initial research on campus from October through December. They will work onsite at your organization during the fall semester, 1 week in October and/or up to 3 weeks in January. They will formally present their conclusions to you at the end of their engagement, together with any specific deliverables you agreed on. 23. What type of project would you like the H-Lab team to work on for your organization? Please select one or more categories that you would like the H-Lab team to work on for you. You and your team will agree to the final project scope. Operations Management Analytics IT Marketing __Strategy Organizational change or development Other Management related Project (please specify): 24. Please describe what challenge or opportunity you would like your H-Lab team to work on for your organization, i.e., what problem are you trying to solve? Please provide relevant background and details about the project. Please also help us understand why this project is important to your firm. (H-Lab projects are most successful when they are strategic or mission-critical to their host organizations.) 25. What work should the team focus on during the fall semester? How can your team best leverage the rich resources available at MIT to prepare for and begin work on your project? Background research? Initial interviews with local sources? Something else? 26. What is the key deliverable that the team should provide to you at the conclusion of their project? In addition to the standard presentation or written report to senior management, please consider if there are concrete deliverables such as spreadsheet tools, organizational dashboard templates, roadmaps for marketing, process improvement diagrams, etc., that would be particularly useful to your organization. 27. OPTIONAL: Please provide any additional information you believe is important. Please give additional organizational background, links, etc. that you believe will help teams understand your organization, your project, and the opportunity to work with you. Project Logistics Students usually will work in teams of 4. If your project is in the Boston area, the team will visit your location during the semester and/or for an intensive week in October. If your project is out of the Boston area, your team will visit you for an intensive work session during January. We ask that H-Lab organizations pay modest travel and lodging expenses (economy airfare and modest accommodations), if travel is required outside of the Boston area. There are no other costs involved for host organizations. 28. What skills and experience are most valuable for the team to bring to the project? Please indicate which abilities would be required and which are preferred. 29. Please confirm that you will pay round-trip economy airfare to and from onsite work, if applicable (outside the greater Boston area). * Yes No __Not Applicable 30. Please confirm that you will provide safe, appropriate accommodations during the onsite work, if applicable (outside the greater Boston area). * Yes No __Not Applicable 31. Please confirm that you will provide appropriate workspace during the onsite work (e.g., desk, internet access, general office supplies, etc.). * Yes No 32. Non-Disclosure Agreements (NDAs): Occasionally, organizations request teams to sign NDAs, depending on the scope of their project. Do you expect to request an NDA? If so, we will connect you with our legal advisor for the appropriate documentation.* Yes No 33. Do you require any medical tests or vaccines from our student teams in order for them to be onsite at your organization? Some hospitals require TB, flu vaccines, etc. If so, we will contact you as soon as possible with student information. * __ Yes __ No __Not Applicable Supporting Documents Please add any supporting documents that might be helpful for the student team to better understand your project or your organization (structure, culture, product(s)/service(s)).