Problem Submission Form Information:

This is the clinical problem submission form for MEDLaunch. In completion of this form, you are aiding MEDLaunch in the crucial initial step of identifying the issues affecting the healthcare system. Following reception of your problem and/or research opportunity, the MEDLaunch executive team and its Board of Directors will evaluate the problem based on criteria including, but not limited to, solution feasibility, development timeline, potential legal complications, affected population size, and marketability. Based on the results of this preliminary evaluation, your problem may become available for selection by MEDLaunch teams that express interest in developing a solution. Should your problem be selected you will be notified via your preferred method of contact.

Full Name (required)

Your Email (required)

Phone (optional)

Preferred Method of Contact (Check all that apply): *
EmailPhone

Name of Employer *

Department *

Problem Title *

Please provide a description of the problem and/or research opportunity you have identified. *

To the best of your ability, please provide a brief background of the problem and/or research opportunity. *

Have you or any of your colleagues conducted research regarding this problem? If so, please provide: (1) the dates of the research, (2) sources of funding, if any, for the research, and (3) names and employers of individuals involved in the research. *

Do you have existing funds or leads for funding MEDLaunch research on this problem? If so, please describe. *

Have you publicly disclosed this idea/problem (in conversation, presentation, publication, or otherwise) prior to submitting this form? If so, where/to whom? *

What category of problem is this? (Check all that apply) *
SystemsSoftwareMedical DeviceOptimization of Current Medical DeviceOther

How would you like to be involved in the design process? Note: Any selection made at the time of submission of this form is not binding. (Check all that apply) *
Option 1: No Additional Involvement - Problem Submission OnlyOption 2: Mentor (This option involves significantly less commitment by the requestor but does not normally guarantee the requestor to hold equity in any company that forms from the team. As an advisor, the requestor is expected to make himself/herself available for the team on an as needed basis, providing feedback and guidance during the design process. In addition, attendance at quarterly design reviews is expected.)Option 3: Champion (This option involves a higher level of commitment but entitles the requestor to hold equity in any company that forms from the team pursuing a solution. Time requirements are variable but may include attending weekly design meetings, in addition to all design reviews. Note: The amount of equity owned by any team member is variable based upon level of involvement and team decision making.)Option 4: Angel (This option involves making a financial contribution to the MEDLaunch team working to solve the problem you have presented.)Option 5: I don’t know / would like to further discuss the options should the problem be accepted by MEDLaunch.