Attachment A

Attachment A

Form Approved

OMB No. 0925-0002

Exp. Date 08/31/2015

NIH-COMMERCIALIZATION ASSISTANCE PROGRAM (CAP) 2012/2013

Commercialization Training Track (CTT)

COMMERCIALIZATION PROGRESS TRACKING FORM- Baseline

(November 2012 to August 2013)

PLEASE SUBMIT BY MM/DD/YYYY

Company Name:

If company name has changed since your participation in CAP, please provide it here:

CAP SBIR/ STTR Grant or Contract #:

Is the technology supported by the above SBIR/STTR Grant or Contract still active with the company’s commercialization efforts? ___ Yes ___ No

The tracking form is divided into four sections: (1) Road-to-the-Deal activities, (2) Funding, (3) Revenue, (4) and Other success indicators (employees, acquisitions). It not only provides you the opportunity to report your measurable achievements, but it also allows for your opinions regarding the impact CAP may have had on your progress.

IMPORTANT: NOTE ON CAP IMPACT

When assessing the CAP impact on partnership activities, funding, and revenue, please consider both the direct and indirect impacts of the program. For example, a direct impact would include introducing you to a potential partner and an indirect impact would include the tools and training delivered by CAP that may have significantly contributed, or in your opinion, would significantly contribute to, the development of a partnership. Thus, “Major Impact” would indicate that CAP significantly influenced the company’s growth whether it be a result that is tangible (a “deal”) or intangible (being better prepared and oriented toward a potential outcome). “Valuable Impact” would indicate that CAP contributed to your growth (tangible or intangible) but the impact was less than “Major.” It is understood that these differences are subjective in nature. However, in either case your assessment as to whether you are “better off” after CAP than you were before you entered the program is what is being sought. “Little or No Impact” is self-explanatory.

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0627). Do not return the completed form to this address.

1. ROAD-TO-THE-DEAL ACTIVITIES

a) Are you currently seeking partnerships? __ Yes ___ No (If No, please skip part b and proceed to answer part c)

b) What kind of partnerships are you considering? (Check one or more, as appropriate):

___ Strategic Partner __ Technical collaboration __ Distribution

___ Other (Please specify) ____________________________________

c) Although you have already stated Yes or No to currently seeking partnerships, please indicate if your company has engaged in any partnership-related activities between November 1, 2012 and August 31, 2013 with regards to your CAP-related technology. Please only state numbers and not qualitative data in the table below.

Activity	Number of road-to-the-deal activities in which your company has engaged during your participation in CAP	Describe Significant Outcomes
Contacts with Partners Count only contacts with whom you had a meaningful conversation with about your mutual interests
Meetings with Partners Meetings can be face-to-face or by phone/web but should involve exploration of potential deals in some detail.
Confidential Disclosure Agreements signed CDA (NDA) agreements are generally a pre-requisite for any serious discussion with potential partners.
Negotiations with Partners At this stage, all parties are interested in the deal and you are exploring various give and take scenarios.
Initial Proposals and Term Sheets These are proposals of key terms of the deal and serve as the basis for a final agreement.
Deals Signed legal documents committing partners to a process, timeframe and outcome. If appropriate to the “deal(s)”, please indicate the dollar amount(s) involved.

d) Please indicate the level of impact of the CAP on your partnership-related activities for the period November 1, 2012 and August 31, 2013. (Note: Please refer to the CAP Impact guideline on the page 1.)

____ Major Impact ____ Valuable Impact ____ Little or No Impact

Comments: _______________________________________________________________________________

_____________ ____________________________________________________________________________

2. FUNDING: EQUITY INVESTMENT, BANK LOANS OR OTHER/ALTERNATIVE FINANCING

a) Are you currently seeking outside financing? __ Yes ___ No (If No, please skip part b and proceed to answer part c)

b) If yes, please check each of the following as appropriate to your situation:

___ Investment (If check, please complete parts c and d only)

___ Bank Loan or Other/Alternative Financing (e.g. receivable financing; please specify) (If check, please complete parts e and f only)

c) Although you have already stated Yes or No to currently seeking outside financing, please indicate the total amount of funding, if any, received by your company including your CAP-related technology in the time period November 1, 2012 and August 31, 2013. Please only state numbers and not qualitative data in the table below.

Investor Party	Amount of Equity Investment
Friends and Family
Angels High net worth individuals; always invest as individuals although may belong to angel organizations.
Venture Capitalists (VCs) Institutional investors
Strategic Investors Investors that are looking to achieve other goals in addition to financial returns; typically, this may include corporations seeking to fill or expand their product lines or corporate “venture arms.”

d) Please indicate the level of impact of the CAP on funding received for the period November 1, 2012 and August 31, 2013. (Note: Please refer to the CAP Impact guideline on the first page.)

____ Major Impact ____ Valuable Impact ____ Little or No Impact

Comments: _______________________________________________________________________________

_____________ ____________________________________________________________________________

e) Although you have already stated Yes or No to currently seeking outside financing, please state the total amount of Bank Loan/Other Financing, if any, received by your company including your CAP-related technology in the time period November 1, 2012 and August 31, 2013. Please only state numbers and not qualitative data.

Bank Loan/Other	Amount of Financing
Bank Loan Financial Institution, include banks and credit unions.
Other/Alternative Financing (e.g. receivable financing); please specify:____________

f) Please indicate the level of impact of the CAP on “Bank Loan” or “Other/Alternative Financing” for the period November 1, 2012 and August 31, 2013. (Note: Please refer to the CAP Impact guideline on the first page.)

____ Major Impact ____ Valuable Impact ____ Little or No Impact

Comments: _______________________________________________________________________________

_____________ ____________________________________________________________________________

3. REVENUE

Please report information for your company and not just your CAP-related technology.

a) Indicate your company’s largest source of revenue in the past 10 months (November 1, 2012 and August 31, 2013) (Choose one only)

____ R&D Grant/Contracts ____ Products or Services ____ Licensing Fees and Royalties

b) What is the dollar range of your company’s cumulative sales of products/services for the past 10 months (November 1, 2012 and August 31, 2013)?

__ No sales yet __ $500,000 - $999,999

__ Less than $50,000 __ $1,000,000 - $4,999,999

__ $50,000 - $99,999 __ $5,000,000 - $9,999,999

__ $100,000 - $499,999 __ $10,000,000 and above, please specify $_______________

c) Please indicate the level of impact of the CAP on your company’s revenue for the period November 1, 2012 and August 31, 2013. (Note: Please refer to the CAP Impact guideline on the first page.)

____ Major Impact ____ Valuable Impact ____ Little or No Impact

Comments: _____________________________________________________________________________

____________ ___________________________________________________________________________

4. OTHER SUCCESS INDICATORS (EMPLOYEES, ACQUISITIONS)

1. Have the number of employees in your company increased since November 2012?
   Yes ___ No ___

If yes, please specify the number of employees in November 2012, versus the current number of employees, and the titles/positions of the new employees in the table below. Count part-time employees as 1 (i.e. do not use fractional numbers to count part-time employees.)

	Employee Information	Titles/Positions
Number of Employees in November 2012
Current Number of Employees

2. If you had an increase in employment,

1. Was it due to obtaining additional SBIR funds?    ___ Yes   ___ No

2. Did CAP influence your ability to hire?  ___ Yes   ___ No

3. Has your company been acquired? ___ Yes ___ No

4. Are you currently in discussion regarding an acquisition? ___ Yes ___ No

1. Has your company been acquired? ___ Yes ___ No

If your answer to either of the above in c) is “Yes”, NIH would like to continue tracking the progress of the SBIR-developed technology. Please provide the following information.

	Acquisition Information
Name of the Acquiring Company
Change in Company Name as a Result of the Acquisition
Change in Company Contact Information as a Result of the Acquisition
Additional Details

THANK YOU ONCE AGAIN FOR YOUR PARTICIPATION IN THE 2012/2013 CAP AND FOR YOUR TIME IN PROVIDING THIS VALUABLE FEEDBACK. IT WAS AN HONOR TO WORK

WITH YOU AND WE WISH YOU THE BEST OF SUCCESS.

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