Prize competition applicants

Form Approved

OMB No.0990-002

Exp. Date XX/XX/20XX

KidneyX Evaluation

Attachment A

Pre-Award Survey

According to the Paperwork Reduction Act of 1995, no persons are 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 0990-XXXX. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

To assess and improve the administration and impact of the KidneyX Initiative, the U.S. Department of Health and Human Services (HHS) has retained RTI International to conduct an external evaluation of the KidneyX prize competition, [name of challenge]. We request that you fill out this survey in conjunction with your submitted application regarding your expectations and experiences in participating in this competition. We estimate that it will take you 20 to 30 minutes to complete your survey. Note that your identity will not be reported to HHS or any organization affiliated with KidneyX, and none of your answers here will be attributed to you. If you have questions about this survey or its contents, please contact Dr. Jeffrey Alexander, project manager for the External Evaluation of KidneyX, at 301-230-4656.

1. Please provide the following personal details: [TEXT BOXES]

   1. Last name/Family name

   2. First name(s)

   3. Names of co-applicants (if any)

2. How many prize applications did you submit for this __ round of the KidneyX prize competition ________?

3. Please indicate which of the following types of organizations you are affiliated with. [MULTIPLE SELECT CHECKBOX]

   1. Company

      1. [IF CHECKED] Please provide the name of the company [TEXT BOX] 

      2. [IF CHECKED] Please select the type of company [SINGLE SELECT] 

         1. Startup company (AUTM definition: A START-UP COMPANYS is a new company dependent on developing or licensing your proposed project for its formation. START-UP COMPANIES refer only to those companies that were formed specifically to develop the technology being proposed. 

         2. Small company (AUTM definition: Companies that had 500 or fewer employees at the time of submission.) 

         3. Large company (AUTM definition: Companies that had more than 500 employees at the time of submission.) 

      3. [IF CHECKED] Is your project’s technology being licensed for development from an external inventor? [Y/N] 

   2. University or academic medical center

   3. Research institution or organization, other than a university

   4. Other

      1. [IF OTHER] Please specify [TEXT BOX]

   5. None (I submitted my proposal as an individual)

4. How many years of experience do you have in the field of kidney health or kidney technology? [DROPDOWN]

5. Are you currently working in the field of kidney health or kidney technology? [Y/N]

   1. Have you received treatment, or are being treated, for a kidney ailment? [Y/N]

   2. Have you ever been a caregiver or care team member for someone suffering from kidney disease?

6. Other than yourself, please list the names and affiliations of others who collaborated with you on your application, if any, and the number of years you have worked together on this project [TEXT BOXES FOR FIRST NAME, LAST NAME, AND AFFILIATION, AND DROPDOWN FOR YEARS]

7. How did you first hear about KidneyX? [SINGLE SELECT]

   1. From an announcement I received directly from KidneyX

   2. From a web site or online posting by the Department of Health & Human Services

   3. From a professional or trade association

   4. From someone at my institution/organization

   5. From a peer or colleague at another employer

   6. From a patient advocacy group

   7. From another patient or care partner

   8. From a conference

   9. From an online search

   10. Other

       1. [IF OTHER] Please specify [TEXT BOX]

8. To what extent do you agree or disagree with the following statements: [LIKERT SCALE]

   1. The information on how to apply was clear.

      1. [NEUTRAL, DISAGREE, OR STRONGLY DISAGREE ONLY] Please briefly explain. [TEXT BOX]

   2. The criteria for participation were clear.

      1. [NEUTRAL, DISAGREE, OR STRONGLY DISAGREE ONLY] Please describe any criteria that you feel may have inadequately defined. [TEXT BOX]

   3. The criteria for winning the prize were clear.

      1. [NEUTRAL, DISAGREE, OR STRONGLY DISAGREE ONLY] Please describe any criteria that you feel may have inadequately defined. [TEXT BOX]

   4. I felt like I was able to completely and accurately present my project within the limitations of the application.

      1. [NEUTRAL, DISAGREE, OR STRONGLY DISAGREE ONLY] Please describe any elements of the application that may have limited the ability to completely and accurately convey your project. [TEXT BOX]

   5. The time and effort required to submit the application was appropriate.

   6. I have high confidence in the KidneyX judging and selection process.

      1. [NEUTRAL, DISAGREE, OR STRONGLY DISAGREE ONLY] Please briefly explain any sources of doubt or lack of confidence in the judging or selection process. [TEXT BOX]

         1. [IF OTHER] Please specify [TEXT BOX]

9. Please estimate the amount of time (in labor-hours) you spent completing the text of your application to this competition. [TEXT BOX]

10. The following reasons motivated me to apply to KidneyX and pursue my project in the kidney health field: [MULTIPLE SELECT]

    1. The promotion, announcements, conferences, and other informational campaigns related to KidneyX helped make me aware of a potential application and/or market for my project that I had previously overlooked.

    2. The potential to win prize money

    3. The potential to receive constructive input to improve my project

    4. The potential to make connections with other funders or private investors

    5. The potential to learn more about regulatory aspects of the kidney health field

    6. The potential to make connections with payers (public and private)

    7. The potential to make connections with patient and caregiver populations

    8. The potential to make connections with other innovators and entrepreneurs in the kidney health field

    9. Other

11. If your application is not selected as a winner, do you plan to continue developing your project in the kidney health field? [SINGLE SELECT]

    1. Yes, almost certainly

    2. Yes, likely

    3. Unsure

    4. No, unlikely

    5. No, almost certainly not

       1. [YES, ALMOST CERTAINLY; YES, LIKELY; AND UNSURE ONLY] If your application is NOT selected as a winner, how important to your future plans is the prospect of receiving any of the following benefits from KidneyX? [NOT IMPORTANT AT ALL, SOMEWHAT IMPORTANT, VERY IMPORTANT]

          1. Technical, scientific, or engineering guidance

          2. Business planning guidance

          3. Regulatory guidance

          4. Access to funding networks

          5. Other

             1. [IF OTHER IS SOMEWHAT OR VERY IMPORTANT] Please specify [TEXT BOX]

12. Please estimate the amount of money invested (by you, your partners, your company or organization, or other internal investors) in your proposed project at the time of your application. [NUMERICAL BOX]

    1. Of that amount, how much was spent after you decided to apply to this competition?

13. Had your proposed project received any in-kind investments from external stakeholders at the time of your application? [Y/N]

    1. [YES ONLY] Please indicate any of the following in-kind investments that apply.

       1. Equipment (donated or loaned)

       2. Labor from experts, assistants, or consultants

       3. Datasets or code

       4. Samples or specimens

       5. Other

          1. [IF OTHER] Please specify [TEXT BOX]

14. Had your proposed project received, attracted, or raised additional funding from outside sources at the time of your application? [Y/N]

    1. [IF YES] Please indicate the source(s) and amount(s) of funding [MULTIPLE SELECT FOR SOURCE BESIDE A NUMERICAL TEXT BOX FOR AMOUNT]

       1. Foundations, Associations, or Non-Profits

       2. U.S. federal agencies

       3. State or local governments

       4. Universities

       5. Angel investors

       6. Venture capital

       7. Corporate/industry strategic partners

       8. Other

          1. [IF OTHER] Please specify [TEXT BOX]

15. Had you published academic literature relevant to your proposed project prior to the time of your application? [Y/N]

    1. [IF YES] Please list the most important publications, including the title, the year, and the journal of the publication. [TEXT BOXES FOR TITLE AND JOURNAL AND DROPDOWN FOR YEAR; RESPONDENT CAN ADD ROWS FOR MULTIPLE PUBLICATIONS]

16. Had you applied for any patents relevant to your proposed project prior to the time of your application? [Y/N]

    1. [IF YES] Please list the patent application number(s) and the associated inventors named on each application. [TEXT BOXES FOR APPLICATION NUMBER AND INVENTORS; RESPONDENT CAN ADD ROWS FOR MULTIPLE APPLICATIONS]