UCL INNOVATION & ENTERPRISE
           UCL’s HEIF Early stage commercialisation application
           1.  Project Info
           Project title
           Call                     Stream: HEIF - ESC
                                    Sub-stream: Early Stage Commercialisation
                                    Call: KEI2022(-XX)
           PI / academic lead       Given Name                                     Last Name
           at UCL
                                    UCL Email                                      UPI
                                    Department
           Co-Investigators at UCL
           Name                                  UCL Email               Department                      UCL UPI
           Declaration of Interest
           Are you in compliance with UCL’s policy            Please provide details as needed e.g. details of interest,
           on Disclosure of Conflicts and                     an explanation if your answer is ‘No’
           Declaration of Interest?
           ☐ Yes ☐ No
           If relevant to this proposal, have you             Please provide any further information if applicable
           disclosed any actual, potential or 
           perceived conflicts of interest to UCL?
           ☐ Yes ☐ No
           Ethical Approval
           Do you require ethical approval for this project?
           ☐ Yes ☐ No
           Confidentiality
           ☐ Yes, my application contains confidential             ☐ No, my application does not contain confidential 
           information that should not be shared publicly          information that should not be shared publicly
           Please provide details:
           2.  Partner Organisation(s) (if any)
          Name
                                                                        1
        UCL INNOVATION & ENTERPRISE
         Organisation type                  ☐ Public – Central Government          ☐ Private – Community Interest 
                                            ☐ Public – Local Government            Company (CIC)
                                            ☐ Public – NGO                         ☐ Charity or Trustee Managed
                                            ☐ Private – Public Limited             ☐ Social Enterprise
                                            Company (PLC)                          ☐ Higher Education Institution
                                            ☐ Private – Limited Company (Ltd)      ☐ Research Institute
                                            ☐ Private – Limited Liability          ☐ Funding Body
                                            Partnership (LLP)                      ☐ Other (please specify)
         Size of company                    ☐ Micro                  ☐ SME           ☐ Large          ☐ Large 
                                            multinational
         Lead contact                       Name                              Email
                                            Job title                         Business phone number
         Address                                  
         Sectors                            ☐ Aerospace, Defence,             ☐ Environment
         (select up to 2)                   Marine                            ☐ Financial Services & Management 
                                            ☐ Agriculture, Food, Drink        Consultancy
                                            ☐ Chemicals                       ☐ Government, Democracy and Justice
                                            ☐ Communities and Social          ☐ Healthcare
                                            Services/Policy                   ☐ Leisure, incl. sports, recreation & 
                                                                              tourism
                                            ☐ Construction                    ☐ Manufacturing, incl. Industrial 
                                            ☐ Creative Economy                Biotechnology
                                            ☐ Culture, Heritage, Museums      ☐ Pharmaceuticals and Medical 
                                            and Collections                   Biotechnology
                                            ☐ Digital/Comms/Info Tech         ☐ Retail
                                                                              ☐ Security, Diplomacy
                                            ☐ Education
                                                                              ☐ Transport
                                            ☐ Electronics                     ☐ Other (please specify)
                                            ☐ Energy
         Is this the first time you have     ☐ Yes ☐ No      ☐ Don’t know
         worked with this partner?
         Details of previous 
         engagement
          3.  Planned Activities
          Summary of aims and objectives of the project:
          Describe fully the activities to be undertaken and how they will increase the impact of the 
          underpinning research
          Describe the role of the partner organisation(s) (if any)
          4.  Impact and risk assessment
          How does this project fit in with the Innovation & Enterprise’s Strategy for 2021-23?
                                                                    2
        UCL INNOVATION & ENTERPRISE
           Provide an outline of why this project matters in ‘real world’ terms:
           Describe (i) anticipated outcomes, (ii) the potential impact and beneficiaries, (iii) measures of 
           success:
           Plan for ongoing activity and securing further funding if project is successful
           Risk assessment and competitor analysis:
           Commercialisation possibilities, including UCLB engagement:
           UCLB Business Manager:
           5.  Track Record
           Summary of                Summary:
           underpinning work 
           and link to grant 
           portfolio                 Project numbers:
                                     Research Council grant(s)                   Other
           Outline of your           Summary: 
           previous 
           engagement in             Project numbers & year received:
           knowledge 
           exchange or               UCL HEIF                      External                       Other UCL
           innovation
           6.  Resources and Financial Details
           Proposed start                                       Proposed end
           Partner                  Details of contribution from partner organisation:
           contribution 
           (if any)                 Cash (£)                    In kind (£)                  Total (£)
           UCL funding              Staffing and recruitment requirements:
           requested
           (£, direct costs 
           only)                    Justification of resources requested:
                                    Salaries        Consumables        Travel           Other              Total
                                    List expected spend by month:
                                                                        3
        UCL INNOVATION & ENTERPRISE
                                  Funding request per financial year (1st Aug–31st July):
                                  Financial Year 1                           Financial Year 2
                                  Financial Year 1 Value (£)                 Financial Year 2 Value (£)
          Funded staff details    Name                                       FTE
          (insert more copies 
          of this section if 
          needed)                 UCL background
                                  ☐ Doctoral student          ☐ Postdoctoral staff      ☐ Teaching
                                  ☐ Other academic staff      ☐ Technical/support      ☐ Other (please specify)
                                  Date from                                  Date to
          Departmental            Given Name: 
          Manager or              Last Name: 
          Departmental            Email: 
          Administrator with 
          budgetary               Department: 
          responsibility          UPI: 
                                  Worktribe ID                               MyFinance Organisational Unit
          7.  Completion & Documents
          Confirm Documents attached
              1.  Standalone Worktribe costings (Excel)
              2.  Costing spreadsheet
              3.  Evidence of Partner Organisation support (i.e., letter or email of support)
          Head of Department
          Head of                 Given Name                                  Last Name
          Department
                                  UCL Email                                   UPI
                                  Department
                                                                    4