Idea Submission Form

To further enhance our potential for commercial impact, we formed a joint venture with i360medical, Ltd – an Ireland-based company with expertise in developing medical devices and bringing them to the global market. i360 provides comprehensive design, engineering and prototyping services as well as clinical, marketing and technical assessments to prioritize Northwell innovations for commercial development.

To start the disclosure intake process and work with an Innovation Manager, please fill out the information below.

Title of Invention

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* 1. Title of Invention

First and Last Name

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* 2. First and Last Name

Title

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* 3. Title

Department/Specialty

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* 5. Department/Specialty

Department Head

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* 6. Department Head

Office Phone Number

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* 7. Office Phone Number

Mobile Phone Number

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* 8. Mobile Phone Number

Primary Email Address

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* 9. Primary Email Address

Secondary Email Address 

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* 10. Secondary Email Address 

Description of Invention

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* 11. Description of Invention

Type of Invention 

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* 12. Type of Invention 

Invention Stage

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* 13. Invention Stage

Type of Patent Application Filed (If Applicable) 

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* 14. Type of Patent Application Filed (If Applicable) 

Patent and/or Application Number

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* 15. Patent and/or Application Number

Intended Specialty of the Idea  (Check all that apply) 

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* 16. Intended Specialty of the Idea  (Check all that apply) 

Unmet Need: Describe how the idea proposes to address an unmet need or problem

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* 17. Unmet Need: Describe how the idea proposes to address an unmet need or problem

Funding Source

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* 18. Funding Source

If yes, was this funded by a federal grant agency?

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* 19. If yes, was this funded by a federal grant agency?

If yes, please enter Funding Institution Grant No(s).

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* 20. If yes, please enter Funding Institution Grant No(s).

Public Disclosure

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* 21. Public Disclosure

If Yes, Type of Public Disclosure 

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* 22. If Yes, Type of Public Disclosure 

Date(s) of Public Disclosure

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* 23. Date(s) of Public Disclosure

Please attach file here (no larger than 16MB)

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* 24. Please attach file here (no larger than 16MB)

DOCX, DOC, JPG, JPEG, PDF, PNG file types only.
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