Emerging Technology/Service Review Request

For use by Existing or Potential Kaiser Permanente Vendors or Partners


 How to use this form:
   o   Use this form to request Kaiser Permanente (KP) to review of an emerging technology or service.
   o   Be sure to enter all information before pressing the Submit button.
   o   Once submitted you will not be able to make changes or additions.
   o   Fields with a '|' (red bar) are required to submit.
   o   Mulitple line text boxes may be expanded by dragging the lower right corner.
   o   Field level help is to the left of many prompts.
   o   If you experience problems submitting your request email the problem details along with submission details by clicking here.

After submission this request will be reviewed and the technology or service evaluated further by technical resources within Kaiser Permanente IT to determine if it may be of value to Kaiser Permanente.
The contact information provided will be used to collect any additional information needed and to inform you of the final results of the review.

Hide Section - Submitter Information

Submitter Information

Enter information about yourself or the person you are submitting for. The submitter will be contacted via email about the general progress and results of the technology/service review.  
Check if someone, other than the Submitter (above), should be contacted for additional technology/service related questions
Check to identify the KP employee that is familiar with this technology/service.
Hide Section - Company/Organization Information

Company/Organization Information

Enter information about the company or organization that offers/sells/develops the technology or service.  
Primary company/organization website.
Max: 450 characters

Stage of development/categorization of the company or organization. Select all that apply.
Enter a single dollar value without commas and no dollar sign.
Full-time employees only.
Company address
Hide Section - Technology/Service Information

Technology/Service Information

Enter information about the technology or service offered.
Enter the official full name of the technology or service.
Describe your technology/service so it’s easy to understand. No marketing collateral. ' (Max: 450 characters)
Technology/Service description web page. Default to company home page if none.
Link to a page by an external 3rd party news source covering the technology/service.

Select all market segments the technology/service is specificially targeted to service.
  • Healthcare - Clinical Grade : the technology is intended for care provider use.
  • Healthcare - Personal : the technology is intented for personal use.
  • Healthcare - Regulated, FDA, etc. : the technology is or will be regulated and is or will be compliant with regulation.
Select the current technology/service stage.
The stage in FDA Clearance for the technology/service, if applicable.
Brief description of the value the technology/service could offer to Kaiser Permanente. Be specific about what areas of Kaiser Permanente might use this technology or service, and for what benefit. (Max: 255 characters)
List of market competitors. (Max: 250 characters)
Check if you require an NDA to engage in detailed discussions about your product.
If you know of a deployment of the technology/service at Kaiser Permanente, then check this and enter details below.
Provide a description of the deployment(s). (where, when, with what department, etc.) (Max: 1000 characters)
Description of any major deployments of the technology/service outside of Kaiser Permanente. (where, when, with what organization, etc.) (Max: 1000 characters)
Enter tags separated by spaces that represent key features, aspects, technology and focus areas of your product. I.e. telehealth mobile_apps big_data geriatrics diabetes social_media compliance. (Max: 32k characters)
Enter any other information that is of value for KP to understand about your product and your organization. (Max: 32k characters)
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