Form

GCMI Pilot Research Request Form

Please complete the following form to participate in the Pilot Research Program at GCMI. If you have any questions, please contact Evan Goldberg at evan.goldberg@t3labs.org

First name*

Last name*

Email*

Please provide all participant name(s), role(s), and Georgia Tech Department or Affiliation*

Provide a brief background/introduction of your research and how it may improve the health of people.

Briefly describe your research plan. Keep in mind that experimentation should be limited to 1-2 hours per group. Models will be shared with other researchers. *

List any personnel support needed during experimentation.*

List any specialty equipment needed (e.g., x-ray, C-arm, power injector, drill, saw, ultrasound, etc.)*

How will the data collected at GCMI be used? Please check all that apply.*

Grant Submission

Publication

Feasibility

Future investment opportunities

Please provide more information (i.e. if this is for a grant, which organization and when will you be applying?)*

Do you currently have funding for your technology?*

Yes

If you do currently have funding, what is the source?*

Self

Grant

Friends and family

Angel Investor

Venture Capital

Corporate Venture

University funding

Other

If other source of funding, please designate source

Will you be forming a company with your technology?*

Yes, I already have a company

Yes, I plan to form a company in the future

No, I do not plan to form a company

Undecided

Additional comments, if any

Have you been involved with (currently or previously) any Georgia Tech organizations to support your technology? (example: Venture Lab, ATDC, Biolocity etc.) If so, please indicate the organization and describe how it is/was involved with your technology.*

Are you interested in any other services GCMI offers?

Design work

Prototyping

Lab space

Preclinical testing

Lifecycle advisory

If you are unaware of GCMI's services and would like to learn more, please check this box.