DHSAC Form

Digital Health Systems Assessment Criteria

Complete the form below provide the assessors the context required to understand your digital health.
Company Information
Name of your Organisation/Company*
Name of Key Contact Person at your Organisation*

First NameLast Name
Key Contact - Job Title*
Key Contact - Email*
Key Contact - Phone Number*

Area CodePhone Number
Registered Address of your Organisation/Company*

Street Address

Street Address Line 2

CityState/Province

Postal / Zip CodeCountry
Name of your Product*
Type of Product*
Implementation Stage*
Technology License*
Technologies Used*
Please enter all the technologies used by your product
Disease Area(s)
If you product addresses a particular disease area

Value Proposition
PatientsDiagnosticsClinical SupportInfrastructureHealth WorkersOther
Clearly define the problem that is intended to be solved by the proposed product.*
Provide a clear description of what the product is designed to do and of how it is expected to be used.*
Describe clearly the intended or proven benefits for users and confirm if / how the benefits have been validated.*

Supporting documentation
Please ensure that when providing evidence, documents are clearly labelled with the name of your company, the question number and the date of submission.
Possible documents to be provided are:
- B6 - User journeys and data flows
- C2.1- External Penetration Test Summary Report
- D1.2.1 - User Journeys and/or how the product fits into a user pathway or journey
- D1.3 - Supporting information showing user acceptance testing to validate usability
- D2.1.1 - Supporting information showing available funding support for the product.
- D3.1.1 - Supporting information detailing the sustainability plan.
Once you submit your application, a copy will be sent to you and we will contact you shortly to update you on the progress of this application.

Thank you!
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Digital Health Systems Assessment Criteria