Healthy Aging Prize for Asian Innovation 2021 Application

Part 1: Applicant Information
Name of Innovation*
This may be the name of a policy, product, program, or initiative, or in some cases it may be the organization name. Please put whichever is most appropriate.
About the Applicant

Indicate any organizations directly involved in creating and/or implementing the innovation that should be listed as awardees if the innovation is selected.
Organization/s*
Name of Representative*
Indicate one person as the main contact for this application.
Title*
Tel. Number*
E-mail Address*
Organization Address*
Country / Region*
Additional Contacts
Please add additional email address who should be CC'd in related correspondence

Part 2: Innovation Information
1. Problem Statement (max. 300 words)
Briefly describe the problem or challenge that your innovation addresses. Please include any additional background information or location specific context that will help us understand the issue.*
2. Description (max. 300 words)
Describe your innovation. In particular, please explain how it addresses the problem that you identified in question 1.*
3. i) Implementation (max. 300 words)
Describe the development and implementation of this innovation. Include any challenges that you needed to overcome in that process.*
3. ii) Timeline (max. 200 words)
Please provide a timeline for your innovation. The timeline should include the start date of the innovation, and should detail other key points in its implementation/development, including future plans.*
4. Impact (max. 600 words)

i) Quantitative: Explain the impact of the innovation in terms of people reached, measurable improvements in health or quality of life, etc., as applicable to your innovation. Please back up this information with metrics and data where possible.

ii) Qualitative: If possible, please provide testimonials from those who have benefited from your innovation or other specific examples of how it has helped.

*If needed, please include supporting documents (e.g., graphs or data) as part of your supplemental materials (see question 8).
4. Impact*
5. Reason for Success (max. 300 words)
Please describe the principles and factors that have contributed to the innovation’s success. In responding, please think about lessons that others might learn from your innovation.*
6. Budget & Sustainability (max. 300 words)

Please provide a brief outline of the budget and the funding sources for the innovation.

—Programs/services: indicate the annual operating costs of the innovation and the sources of funding and whether it is financially sustainable (e.g., is the program fee-based, funded through grants, supported by the government, etc.?)

—Products: What is the cost or fee structure for the product?

—If appropriate, applicants may submit a simple budget to illustrate income and expenditures specifically related to the innovation (budget can be submitted as an attachment; please see question 8 on the next page to upload any budget attachments)
6. Budget & Sustainability (max. 300 words) *

Part 3: Supplementary Section (optional)
7. Further Information About the Applicant (max. 200 words)
In addition to the information above, is there anything else you feel is important for the selection committee to know about the organization or innovation?
8. Supporting Materials
Applicants are welcome to submit materials that will assist us in evaluating the innovation. Please submit no more than 10 pages total as supplementary materials. Materials in excess of this amount may not be considered by the committee.

* Clearly note the name of the nominated innovation on any submissions.

—Supplementary materials may include, but are not limited to, the following: websites, photographs, print materials (brochures, fact sheets, flyers, etc.).

—We encourage applicants to submit supplementary materials that are in English. We will look at materials submitted in other languages, but will not be able to translate those materials or evaluate their written content.

—You may include supporting materials at the time of your submission of this form to
ahwin@jcie.or.jp
Upload Your Files

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Website Information
List any website that describes your innovation, URLs for media coverage of your innovation, social media, etc.

Signature (required)
Your Name*

First NameLast Name
Please submit your application no later than March 12, 2021

You should receive a confirmation email automatically after you submit your application. If you have not received a confirmation email within 24 hours, please contact the secretariat via email (ahwin@jcie.or.jp).
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Part 1: Applicant Information

About the Applicant

Part 2: Innovation Information

Part 3: Supplementary Section (optional)

Signature (required)