Test SA1

To be eligible for taking part in the COVID-19 Response Call within the DIH-HERO project all of the following criteria must be fulfilled:
1. Third parties receiving financial support must be a legal entity, being an SME or a slightly larger company from EU (and its associated countries)/EEA countries;
2. The proposal must clearly state the relevant clinical demand and the healthcare problem related to COVID-19 to be solved by the proposed robotic application as well as the added clinical value of the solution;
3. The proposed solution must be an already existing robotic system that is in the later stages of development (TRL7-8) and deployable by the 4 healthcare end-users
4. The proposal must fit to the call text;
5. A third party may not receive more than €300k total grant funding from the DIH-HERO FSTP calls;
6. Proposal must be written in English and submitted via the portal before the deadline;
7. There must be no conflicts of interests with DIH-HERO consortium partners;
8. Third parties receiving financial support must be financially healthy (a financial declaration must be signed as a condition of the award)
For further information and requirements please see COVID-19 Response Applicant Guide.

If you are sure to fulfil all the criteria given above, please continue with the next section.

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Required Information

The following information will be required in the submission form:
1. Administrative Data: Basic contact data of the project partners (e.g. full name of legal entity, type of organisation, company registration number, place of registration, VAT no., name of managing director of the coordinating SME/slightly larger company, address, company website, as well as the name, telephone number and email address of the main contact person(s) and letters support of the end-users);
2. Key Data of the COVID-19 Response Project: (e.g. full title of the COVID-19 Response project; short name of the COVID-19 Response Project; brief description (short abstract of approx. 8 -12 lines); targeted application domain; current TRL; project duration; Statement on legal agreement describing the rights and duties of each party to be negotiated among consortium partners), and statement on the announcement for publication (both given in the online form)
3. COVID-19 Response Project Proposal to be uploaded in pdf format;
4. COVID-19 Response Estimated budget to be uploaded in pdf format
5. Signed Declaration of Honour from all partners saved in pdf format;
6. Signed Declaration of informed Consent for Data Processing from all partners saved in pdf format;
7. Questions for statistical purposes (given in the online form)

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1. COVID-19 Response: Partner Information

Please provide the general information about the project partners.
Fields marked with a (*) are required.
Partner 1 (SME or slightly larger company coordinating the COVID-19 Response project)
Full name of legal entity*
Type of company*

Please state the legal form of the entity.
SME or slightly larger company*
- We confirm that we fulfill all criteria qualifying as a SME according to the EC definition.
- We confirm that we fulfill all criteria qualifying as a slightly larger company according to the EC definition.
Results of SME Self-assessment questionnaire*
Accepted file types: pdf, Max. file size: 200 MB.
Please upload the result page of the SME self-assessment questionnaire here as pdf, even if you do not qualify as SME but as a slightly larger company.
Company registration number*

This is the official registration number at which your company is registered in your country (e.g. chamber of commerce).
Place of registration*
VAT number*
Name of Managing Director*
PIC code (optional)

This is a 9-digit number serving as a unique identifier for organisations (legal entities) participating in EU funding programmes. If you have not participated in an EU funding programme before, please move to the next question.
Address*
Street Address ZIP / Postal Code City Country
Company website*
Main contact person

Please provide the contact information of the person who administers the entire process.

An account will be created using the provided email address.
Name*
First Last
Telephone*
Email address*

We advise you to use a functional email address that is not tied to a single person.
Are you already registered at DIH-HERO?
- Yes
- No

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COVID-19 Response: Partner 2
Full name of legal entity end-user 1*
End-user 1*
- We confirm that we fulfill all criteria qualifying as an end-user.
Type of end-user*

Please specify the type of healthcare-related organisation.
Address*
Street Address ZIP / Postal Code City Country
Website*
Letter of support of end-user 1*
Max. file size: 200 MB.
Please upload the letter of support of end-user 1 here.
Main contact person

Please provide the contact information of the person who administers the entire process for Partner 2.
Name*
First Last
Telephone*
Email address*

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COVID-19 Response: Partner 3
Full name of legal entity end-user 2*
End-user 2*
- We confirm that we fulfill all criteria qualifying as an end-user.
Type of end-user*

Please specify the type of healthcare-related organisation.
Address*
Street Address ZIP / Postal Code City Country
Website*
Letter of support of end-user 2*
Max. file size: 200 MB.
Please upload the letter of support of end-user 2 here.
Main contact person

Please provide the contact information of the person who administers the entire process for Partner 3.
Name*
First Last
Telephone
Email address

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COVID-19 Response: Partner 4
Full name of legal entity
End-user 3
- We confirm that we fulfill all criteria qualifying as an end-user.
Type of end-user

Please specify the type of healthcare-related organisation.
Address
Street Address ZIP / Postal Code City Country
Website
Letter of support of end-user 3
Max. file size: 200 MB.
Please upload the letter of support of end-user 3 here.
Main contact person

Please provide the contact information of the person who administers the entire process for Partner 4.
Name
First Last
Telephone
Email address

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COVID-19 Response: Partner 5
Full name of legal entity
End-user 4
- We confirm that we fulfill all criteria qualifying as an end-user.
Type of end-user

Please specify the type of healthcare-related organisation.
Address
Street Address ZIP / Postal Code City Country
Website
Letter of support of end-user 4
Max. file size: 200 MB.
Please upload the letter of support of end-user 4 here.
Main contact person

Please provide the contact information of the person who administers the entire process for Partner 5.
Name
First Last
Telephone
Email address
Additional Partner 6 (optional)
- Add an additional partner

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COVID-19 Response Partner 6
Full name of legal entity*
Type of organisation*

Please specify the type of organisation.
SME, slightly larger company, end-user or other organisation*
- We confirm that we fulfill all criteria qualifying as a SME according to the EC definition.
- We confirm that we fulfill all criteria qualifying as a slightly larger company according to the EC definition.
- We confirm that we fulfill all criteria qualifying as an end-user.
- We confirm that we are not an SME, slightly larger company or end-user.
Results of SME Self-assessment questionnaire*
Accepted file types: pdf, Max. file size: 200 MB.
Please upload the result page of the SME self-assessment questionnaire here as pdf, even if you do not qualify as SME.
Company registration number*

This is the official registration number at which your company is registered in your country (e.g. chamber of commerce).
Place of registration*
PIC code (optional)

This is a 9-digit number serving as a unique identifier for organisations (legal entities) participating in EU funding programmes. If you have not participated in an EU funding programme before, please move to the next question.
Address*
Street Address ZIP / Postal Code City Country
Company website*
Additional Partner 7 (Optional)
- Add an additional partner

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COVID-19 Response Partner 7
Full name of legal entity*
Type of company*

Please specify the type of organisation.
SME, slightly larger company, end-user or other organisation*
- We confirm that we fulfill all criteria qualifying as a SME according to the EC definition.
- We confirm that we fulfill all criteria qualifying as a slightly larger company according to the EC definition.
- We confirm that we fulfill all criteria qualifying as an end-user according to the definition.
- We confirm that we are not an SME, slightly larger company or end-user.
Results of SME Self-assessment questionnaire*
Accepted file types: pdf, Max. file size: 200 MB.
Please upload the result page of the SME self-assessment questionnaire here as pdf, even if you do not qualify as SME.
Company registration number*

This is the official registration number at which your company is registered in your country (e.g. chamber of commerce).
Place of registration*
PIC code (optional)

This is a 9-digit number serving as a unique identifier for organisations (legal entities) participating in EU funding programmes. If you have not participated in an EU funding programme before, please move to the next question.
Address*
Street Address ZIP / Postal Code City Country
Company website

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2. Key Data of the COVID-19 Response Project

Please provide the general information about the project here.
Fields marked with a (*) are required.
Full title of the COVID-19 Response project*
Short name of the COVID-19 Response project*
COVID-19 Response project abstract*
Please give a short description of your COVID-19 Response project including purpose, aim and a short explanation on how and in what healthcare settings you would like to deploy the robotic application and what would be the major impact. Approximately 8-12 lines
Clinical need to be addressed by the COVID-19 Response project*
Please describe the clinical problem which should be addressed/solved by the COVID-19 Response project. (Approx. 8-12 lines)
Major healthcare robotics application domain targeted by the COVID-19 Response project*
- Diagnostic Robotics
- Interventional Robotics
- Rehabilitation Robotics
- Robotics supporting patients
- Robotics supporting healthcare professionals
Please choose the major healthcare robotics application domain targeted by the COVID-19 Response project.
Starting TRL*
Please give the TRL the innovation has at the start of the COVID-19 Response project and explain briefly why you consider your innovation to be at the current TRL.
Expected duration of the COVID-19 Response project*

The maximum duration of the COVID-19 Response project is ≤ 9 months.
Statement concerning legal agreement among the TD project partners*
- The COVID-19 Response project partners will negotiate and sign an agreement describing all rights and duties of each party involved. If the COVID-19 Response will be financially supported, we will send it by email no later than one month after the COVID-19 Response start to: dih-healthcare@utwente.nl
- The COVID-19 Response project partners have already signed an agreement describing all rights and duties of each party involved. If the COVID-19 Response will be financially supported, we will send it by email no later than one month after the COVID-19 Response start to: dih-healthcare@utwente.nl
Statement on publishing the key data of the COVID-19 Response project*
- The COVID-19 Response key data can be published after approval of the COVID-19 Response financial support.
Statement on publishing the COVID-19 Response project abstract*
- The COVID-19 Response project abstract can be published at the end of the COVID-19 Response and after the delivery of the public abstract.

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4. COVID-19 Response project proposal

Please upload your COVID-19 Response project proposal as well a the accompanying declarations here.
Fields marked with a (*) are required.
DIH-HERO COVID-19 Response project proposal*
Accepted file types: pdf, Max. file size: 200 MB.
Please find the COVID-19 Response proposal template here.
Budget estimation*
Max. file size: 200 MB.
Please find the template for the budget estimation here.
Signed declaration of honour of all the project partners*
Drop files here or

Max. file size: 200 MB.
Please upload the declarations of honour of all project partners in pdf format here.
Signed declaration of informed consent for data processing and storage of all the project partners*
Drop files here or

Max. file size: 200 MB.
Please upload the declaration of informed consent for data processing and storage of all project partners in pdf format here.

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Privacy statement*
I agree to the privacy statement of DIH-HERO

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SA1: Application for SA

Required Information

1. COVID-19 Response: Partner Information

Partner 1 (SME or slightly larger company coordinating the COVID-19 Response project)

Main contact person

COVID-19 Response: Partner 2

Main contact person

COVID-19 Response: Partner 3

Main contact person

COVID-19 Response: Partner 4

Main contact person

COVID-19 Response: Partner 5

Main contact person

COVID-19 Response Partner 6

COVID-19 Response Partner 7

2. Key Data of the COVID-19 Response Project

4. COVID-19 Response project proposal

5. Questions for statistical purposes