Devices, Tools or Related Information Concept Submission Form

Title of Device/Tool:

This research was funded in whole or in part by:

If funded by "Other", please describe:

Referred by:

By whom?:

Organization Name:

Lead Individual’s Name:

Street Address:

E-Mail:

Phone:

Website:
(If applicable)

(Check 4 most closely associated)

Other Topic Area:

(Check 4 most closely associated)

Other Population:

What is the purpose of this submission? (What do you hope to gain as a result of this concept submission? e.g. "Request dissemination of information about this device/tool throughout DoD" or "Request DCoE be aware of our device that shows improved outcomes for PTSD/TBI") (2000 word limit)

 

Focus of Device/Tool (e.g. What does the device do? What were the results? What are the implications for populations of interest to DCoE?) (2000 word limit)

Device/Tool components (e.g. What is used? How is it used? How long is the device/tool used?), etc.) (2000 word limit)

Demographics (e.g. "This device assists active duty Service Members post-deployment" or "This device/tool is for inpatient treatment of adolescent military family members ages 12-18 with mood disorders") (2000 word limit)

Current Populations where device/tool already in use (e.g. Has device been used in populations? Where/When/Outcomes, contact information of location and/or points of contact?) (2000 word limit)

Contraindications for Device/Tool (e.g. What populations are not recommended to use this device/tool? What are the limitations of the device?) (2000 word limit)

Approvals for Third Party Reimbursement (i.e. insurers who have approved)

Future activities/plans (e.g. "We will be presenting this device at _____" or "We are refining/expanding our device to _____” or "We have applied for a grant with _______.”) (2000 word limit)

Additional information DCoE should know (2000 word limit)

Please list supporting empirical evidence for use of the device. If anecdotal evidence please list as such.

Randomized Controlled Studies: (citation or short paragraph for each or Not/Available)

Case Studies/Case Reports/Anecdotal Evidence: (Citation or short paragraph or N/A)

By completing the submission form, you are agreeing to have your submission reviewed by a representative of DCoE who may wish to contact you for further information related to your submission.

DCoE does not award contracts, provide research grants or offer other forms of financial support.

DCoE does not purchase programs, services or products through the concept submission process.

If you are seeking funding please visit: http://www.usamraa.army.mil/pages/baa_forms/index.cfm

For grant announcements please visit: www.grants.gov

For additional information, please visit the TRICARE Management Activity Acquisitions website: http://tricare.mil/tma/ams/