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.

* 1. Title of Invention

* 2. First and Last Name

* 3. Title

* 5. Department/Specialty

* 6. Department Head

* 7. Office Phone Number

* 8. Mobile Phone Number

* 9. Primary Email Address

* 10. Secondary Email Address 

* 11. Description of Invention

* 12. Type of Invention 

* 13. Invention Stage

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

* 15. Patent and/or Application Number

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

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

* 18. Funding Source

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

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

* 21. Public Disclosure

* 22. If Yes, Type of Public Disclosure 

* 23. Date(s) of Public Disclosure

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

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