USDA Small Business Innovation Research (SBIR) Program Phase III Commercialization Survey

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USDA Small Business Innovation Research (SBIR) Program Phase III Commercialization Survey

PLEASE SUBMIT SURVEY ELECTRONICALLY BY: (Month, Date, Year)

This survey provides you the opportunity to report measurable commercialization achievements related to the USDA SBIR Phase II grant # (grant number to be auto populated) that your company received on (year to be autopopulated). This information is vital for the USDA to evaluate and enhance its SBIR program.

This survey should take you no more than one hour to complete. You do not have to complete the survey in one session, but you can save your progress and complete at your convenience. Please answer the questions as comprehensively as possible. All information provided will be held in the strictest of confidence and will only be available to USDA. All quantitative data will be used for aggregate statistical purposes only, and your responses to questions asked will not affect future funding decisions should you apply for SBIR grants in the future.

The survey is divided into seven (7) sections:

1. Company & Phase II Grant Information

2. Partnership-Related Activities

3. Funding: Third-Party Investment

4. Revenue & Sales

5. Intellectual Property Assets

6. Other Success Indicators (Employees, Acquisitions)

7. Company Achievements

The CEO of the company or main person responsible for the upkeep and validity of your firm’s commercialization information is strongly encouraged to be the primary person completing this form.

1. COMPANY & PHASE II GRANT INFORMATION

1. Company / Organization Name. Autopopulate

This is the name of your company when it received the above USDA Phase II grant.

If the company’s name has changed since you received the Phase II grant, please provide the current name. ___________

2. Mailing Address Autopopulate

This is the address of your company when it received the above USDA Phase II grant.

If the company address has changed since you received the Phase II grant, please provide the current address.

Address 1

Address 2

City

State

ZIP / Postal Code

3. Company CEO

First Name

Last Name

Phone

E-mail Address

4. Company Type:

Women-Owned Socially & Economically Disadvantaged

5. Year Company Founded

6. Company Website URL: http:///

7. USDA SBIR Phase II Grant # Autopopulate

8. Title of SBIR Phase II Project Autopopulate

9. Description of SBIR Phase II Project

10. Have you participated in any commercialization assistance, accelerator, or incubator programs? Commercialization Assistance Programs are generally provided by third party subcontractors that aid small businesses that are seeking mentoring, advising, and network building that will contribute to their commercialization activities.

Yes No

If answered YES to (j), the following question will display:

Please indicate which program______________

11. Is the company currently working on commercializing the technology built with the above SBIR grant?

Yes No

If answered NO to (k), the following question will display:

Please explain what happen to the technology supported by the above SBIR grant.

• Company abandoned the technology.

• Company sold the technology.

• Company modified the technology and created a new product that is currently being commercialized.

• Other, please specify:_____________

If answered YES to (k), the following question will display:

12. Stage of Technology Development (check all that apply)

• R&D

• Feasibility or Proof of Concept

• Product Development

• Market Development

• Manufacturing Stage

• Clinical Trials (if applicable)

• Revenue

For the remaining sections of the survey, please provide information relating to the technology funded by this specific Phase II grant unless otherwise indicated.

2. PARTNERSHIP-RELATED ACTIVITIES

1. With regards to your USDA SBIR-funded technology, have you secured partnerships for the commercialization of the associated technology since the time you received the Phase II grant?

Yes No Not Applicable

If answered YES to (a), the following questions in (b) will display.

If answered NO to (a), skip to question (c).

2. State the number of partnership-related activities in which your company has engaged in since you received your Phase II grant.

Activity	Number and kind of partnership-related activities	Describe Significant Outcomes
Confidential Disclosure Agreements Signed CDA (NDA) agreements are generally a pre-requisite for any serious discussion with potential partners.	_____ Strategic Partner _____ Technical collaboration _____ Distribution _____ Licensing _____ Manufacturing _____ Other (Please specify)
Initial Proposals & Term Sheets These are proposals or documents that outline key terms of the deal and serve as the basis for a final agreement.	_____ Strategic Partner _____ Technical collaboration _____ Distribution _____ Licensing _____ Manufacturing _____ Other (Please specify)
Deals Deals are signed legal documents committing partners to a process, timeframe and outcome. If appropriate to the “deal(s)”, please indicate the dollar amount(s) and/or parties involved.	_____ Strategic Partner _____ Technical collaboration _____ Distribution _____ Licensing _____ Manufacturing _____ Other (Please specify)

3. Indicate the type of partnerships you were seeking and identify the main challenges you faced that prevented you from securing a deal. “Deals” are signed legal documents committing partners to a process, timeframe and outcome.

_____ Strategic Partner

_____ Technical collaboration

_____ Distribution

_____ Licensing

_____ Manufacturing

_____ Other (Please specify) _________________

3. FUNDING: THIRD-PARTY INVESTMENT

This section focuses on your commercialization progress in terms of third-party investment you may have received since you received the Phase II grant. For the purpose of this survey, “third-party investment” is described as investment made by any source other than the USDA SBIR/STTR program (Phase I or Phase II) in activities that further the development and/or commercialization of the specific technology developed under the Phase II project.

1. Since you received the Phase II grant, has your company secured third-party investment?

Yes No

If answered NO to (a), answer question (b).

If answered YES to (a), skip to question (c).

2. Were you seeking new sources of third-party investment, and if so, please identify the main challenge(s) you faced that prevented you from securing funding.

3. Please state the total amount of third-party investment your company has secured since you received the Phase II grant. $ ___________

4. Please state the total amount of funding by source that you received for the specific SBIR-funded technology since you received the Phase II grant.

Third-Party Source and Type	Amount of Third-Party Investment	Name of Investing Party
Dilutive (Equity) Investment	Automatically sum amounts from categories below.
Friends & Family
Angels High net worth individuals that invest as individuals although they may also 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.”
Crowdfunding
Non-dilutive Investment	Automatically sum amounts from categories below.
Other SBIR/STTR grants (not from USDA)
Other Federal grants (not from the SBIR/STTR programs)
Other State / Local Government grants
Foundation grants

4. REVENUE & SALES

The following questions focus on revenue and sales generated by the specific USDA SBIR-funded technology.

1. Indicate your company’s largest source of revenue. (Choose one only)

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

2. Since you received the Phase II grant, what is the dollar range of your company’s cumulative sales of products/services in 2014 (January to December 2014)? “Sales” includes cash revenue from the sale of new products or non-R&D services embodying the specific technology developed under this Phase II project

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 $_______________

3. What is the dollar range of your company’s cumulative sales of products/services in the last 5 years (between 2010 to 2015)? “Sales” includes cash revenue from the sale of new products or non-R&D services embodying the specific technology developed under this Phase II project.

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 $_______________

4. Is the technology developed under this Phase II project still generating sales for the Company?
   _____ Yes _____ No

If answered YES to (d), the following question will display:

If answered NO to (d), skip to question (f):

5. How is your technology being offered commercially?

Stand-alone product

Stand-alone service

Part of a system

Other, please specify_________

6. What happened to the technology? Where is it now?

5. INTELLECTUAL PROPERTY ASSETS

1. SBIR-funded Technology’s Intellectual Property Profile:

Which of the following IP protection methods did you use as part of your IP Strategy for the technology developed under this Phase II grant? Specify the number, or enter 0 if not applicable

Number of Disclosures:

Number of Provisional Patents:

Number of U.S. Granted Patents:

Number of International Granted Patents:

Number of Copyrights:

Number of Trademarks:

Number of Trade Secrets:

2. Have you reported all patents related to your SBIR-funded technology to iEdison per the requirements of the Bayh-Dole Act?

Yes No Not Applicable

If answered NO to (b), the following question will display:

Please explain why you did not or were unable to report all patents.

6. OTHER SUCCESS INDICATORS (EMPLOYEES, ACQUISITIONS)

1. Please specify the number of employees at the time you received the Phase II grant.

2. Please specify the current number of employees. ___

3. If you had an increase in employment, did the Phase II SBIR grant impact your ability to hire? 
   Yes No

4. Since you received your Phase II grant, has your company been acquired?

Yes No

If answered YES in (d), 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

7. COMPANY ACHIEVEMENTS

If you have any notable achievements, accomplishments, or awards that you did not include in the survey, please include it in this section (ie., significant milestones, specific partnerships and collaborations, awards, etc.).

Please feel free to share a quote on the impact that the USDA SBIR Phase II grant had on your company’s success.

I give USDA permission to communicate the achievements or accomplishments of my company as part of the SBIR program.

USDA can use my name and company name in those publications.

Thank you for completing this survey and for your time in providing this valuable feedback.

Burden Statement

According to the Paperwork Reduction Act of 1995 an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0524-XXXX. The time required to complete this information is estimated to average 1 hour per response for the Small Business Innovation Research (SBIR) including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing reviewing the collection of information.

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