Initial Industry Engagement - Enquiry Form

Date: / (Office Use Only) Ref:
Company:
Parent Company (if relevant):
Industry:
Company Website Address:
Contact Details:
Contact Name: / Primary
Contact / Other
Contact
Email Address:
Phone Number:
Disease Area / Area of Unmet Need
Proposed Trial Type / FIM Phase I Phase II Phase I / II Combination Other

Please complete all relevant sections below

Potential Collaboration/Research Summary
Proposed Project / Research Title
What type of support is the company looking for?e.g. collaborative research, commercial contract research, study development, market access, regulatory approval, pre-clinical studies, biomarker development ... *
Does the company have full funding available to support any research studies? (check the relevant box) / Yes No
For collaborative studies without full commercial funding, please provide details of any funding routes you have considered, e.g. venture capital, grant applications, charity funding, third party collaboration, ...
For collaborative research, describe your company’s approach to sharing IP.Would the company be prepared to share IP?
For contract research studies, please provide anon-confidential one page study synopsis and/or draft research protocol.
For collaborative research opportunities, please provide a brief description of the following:
  • Your potential therapy/technology;
  • The research questions you are looking to answer and timelines within which you need to deliver the research;
  • The support required through the ECMC Network

What are the potential benefits (patient, NHS, academic, economic) of your potential therapy/technology? What are the potential scientific benefits for clinical academic researchers working with your company and potential therapy/technology?
Please provide any additional supporting non-confidential data that you would be happy for the ECMC Programme Office to share with clinical academics.
Would you like your research opportunity to be referredto CRUK’s Centre for Drug Development (CDD) teams as follows:
Combinations Alliance / Yes No
Clinical Development Partnerships (CDP) / Yes No

If you have indicated yes to any of the above, your details will be forwarded to the relevant CDD teams, where you will be contacted separately.

Next Steps:
Please return completed Enquiry Formfor review by the ECMC Programme Office to:
Telephone contacts: 020 3469 8343 or 020 3469 5381
The Enquiry Form along with any attached non-confidentialinformation will be forwarded to all ECMC Locations (unless specified) as an Expression of Interest (EoI) Call for their completion within 5 working days. Any interested parties will respond to the ECMC Programme Office where we will forward you a collated Group EoI prior to execution of the ECMC Non-Disclosure Agreement (NDA) for further discussions.
By providing us with any personal data, you consent to the collection and use of any information you provide in accordance with the above purposes and to CRUK’s privacy statement.

*Definitions:

  • Collaborative researche.g, investigator-led study – company working in close collaboration with clinical academics, with input into study design and scientific objectives of the study.This could be fully funded by commercial partner,third party funding (e.g. grant application) or a shared risk reward model.
  • Commercial contract research – fully commercial funded and defined study protcol in place but need support in ECMC Location selection and feasibility assessment.

Please complete this section for monitoring purposes only
How did you find out about the ECMC Network? / Online search engine
Word of mouth / recommendation
Presentation at conference / exhibition / Referral by ECMC Clinician/Scientist
Referral by NOCRI
Other
Further details:
ECMC Network /
Combinations Alliance /
CRUK CDD Clinical Development Partnerships (CDP) /

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ECMC Initial Industry Engagement Form_v1.2