Category: Innovation in Medical Technology

Application form

The award recognises any innovation in equipment or techniques which has resulted in better healthcare practice in India.

Eligibility Criteria:

  • Any organization participating in the Awards must have at least 2 years of registered presence and operations in India as March 31, 2015
  • The Initiative should be completely executed in the Indian operations of the participant
  • The Awards shall be given to the initiatives in the healthcare sector for the period January1, 2014 to March 31, 2015
  • Participating organizations must be engaged primarily in providing health care services.
  • Nursing homes, dispensaries, dental facilities and non-allopathic facilities cannot apply.
  • Participation is restricted to organizations subscribing to the allopathic system of medicine only
  • Employees and immediate family members of the award management, sponsors and partners of the awards are not allowed to participate in the Awards
  • Participation in the awards is subject to defined rules and regulations available on website

Instructions for completing this Application form

  • Please use permanent ink while completing the form.
  • Forms should be filled in English and Block Letters only.
  • All questions must be answered. Incomplete forms will not be considered.
  • A participating organisation can send entries in more than one award category or apply multiple times in the same category provided it is for a separate innovation project / initiative. A separate form should be used for each application entry. One form cannot be used for multiple projects / initiatives.
  • Please maintain one copy of the completed form with you for your records

If you have any questions, or require any clarifications, please contact Mr Anirudh Sen 011- 23487445; Mr Syed Quasim Ali at 011- 23487220

List of Documents

Mandatory document(These documents are mandatory to provide. Unavailability of these documents can result in disqualification of the participant)

  • Signed & stamped Declaration by the Authorised person of the organisation
  • Copy of certification mentioned in the form

Additional documents(These documents are not mandatory; however, Participantscan provide them to support their application and claims)

Please note: Additional documents submitted should be relating to the project / initiative submitted for review. Any other document will be disqualified and will not be submitted to the Jury for review.

  • Project report with budgets and approvals
  • Reports to evidence measurable impact
  • Current year Annual report
  • Awards, certifications, accolades etc
  • Brochures, write ups, audio video, presentations, booklets, references
  • Any other information you would like to highlight

Section 1 – Participant information

Private organisation
 Public organisation
 Single speciality (Hospital in which a single speciality accounts for more than 70% of the total patients (or in-patients where in-patient facilities are available)
If yes, Speciality:______, % of Revenue contribution: ______
 Multispecialty hospital (Hospital which provides 5 basic specialities and having more than 50 beds)
If yes, Total beds ______, Specialities & Revenue contribution ______
 Small healthcare organization - Private(Hospital with less than 50 beds)
 Public (Hospital with more than 50beds, District hospital/ Sub-district hospital-Category 2)
 Small healthcare organization-Public (Hospital with less than 50beds,Sub-district hospital-Category1)
Name of participating entity
Name of Corporate or Group, Parent company or Trust
If part of a Corporate or Group or Parent company or Trust to which the participating entity belongs
Number of centers / branches / offices
Number of cities with presence
Contact person / Name:
Email:
Contact:
Address of registered office in India
Year of incorporation
Revenue (Rs. in crores) / Less than 25 / 26 - 100 / 101 -250 / More than 250

Section2 – Case study

Please enter factual and specific information for the jury to evaluate. You could attach additional sheets if required. Please provide up to 3 supporting documents wherever applicable, to support your entry details
INNOVATON
  1. Describe the situation prior to the development of the technological initiative / project. (Highlight the problems and challenges faced which lead to the development of the technology)( Max 500 words )

  1. Describe the steps implemented by you to address the above problem.
Highlight the following:
  1. Objectives of the initiative / project( Max 50 words )
  2. Success measures of the initiative / project( Max 50 words )
  3. Time to implement the initiative / project( Max 50 words )
  4. Details of the initiative / project( Max 150 words )

  1. Describe unique aspects of the initiative / project. Highlight how innovatively the project was implemented in your premises to mitigate the risks involved (Give examples of how implementation of equipment or technology has resulted in improvement of healthcare industry) ( Max 300 words )

IMPACT
  1. Describe measurable metrics to demonstrate the success of your initiative / project (How the use of technology has improved the quality, safety & efficiency of healthcare delivery system.) ( Max 500 words )

5. Describe the impact of your initiatives on the following areas (max 80 words per area)
Stakeholder / Impact
Participating Organisation
Industry
Employees
Others (please specify)
Sustainability
  1. Demonstrate the long-term strategic vision with regard to building and financing sustainable business growth with implementation of the technological initiative / project ( Max 500 words )

Section 3 – Participant Declaration
I declare that the information provided in this entry form is correct and accurate to the best of my knowledge. I agree to abide by the rules and regulations of participation. I /We agree, on behalf of my/ our Organization authorise the award management to use the content submitted as part of my/our entry, in whole or in part and use and display such entry, which shall include trade publications, press releases, electronic posting to the Awards website, electronic hyperlinks to the website of the Participant, and any display format selected by the award management during the awards ceremony or at a later point in time, for a period of five years.
Participant’s name: ______
Signature: ______
Designation: ______
Date: ______
* The Application Form needs to be signed by the authorized signatory from the participant organization (Senior Management)