Hearing Therapeutics Initiative Engagement Form First name(Required) Last name(Required) Email address(Required) Phone number(Required) Address(Required) Street Address Address Line 2 City Post code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Organisation(Required) Organisation's website(Required) Type of organisation(Required) Academia Non-profit organization Research and Technology Institution Small business (<50 employees and annual turnover under €10 million) Medium business (<250 employees and annual turnover under €50 million) Large business Does your organization have an operating plan and existing funding to sustain operation for the next 12 months? Yes No Do you presently receive funding from any of the following? (Check all that apply) Royal National Institute for Deaf People Fondation Pour l’Audition Alzheimer’s Research UK Medical Research Council Wellcome Trust NIHR Innovate UK Other What type of support are you hoping to receive for this project from the Hearing Therapeutics Initiative? (Check all that apply) Link with experts in hearing research Link with experts in preclinical research Link with clinicians Link with experts in early drug discovery Link with experts in clinical trial design and delivery Link with experts in cell and gene therapies Link with specialist CROs and CMOs Access licensing and partnership opportunities Access clinical trial delivery infrastructure Market intelligence Patient insight General support Research collaboration Research funding Other Which of the following are you developing? Therapeutic Diagnostic What is the therapeutic approach of your research? Otoprotection Regeneration Cell and gene therapy Reduction of tinnitus perception Central auditory disorders What is the lead indication? Age-related hearing loss Noise-induced hearing loss Drug-induced hearing loss Congenital sensorineural hearing loss Sudden hearing loss Tinnitus Central Auditory Pathology Cochlear Implant users Please describe your product/therapeutic modality/technique, route of administration and therapeutic target.500 words maximum. Please do not include confidential information but do provide sufficient data to allow a knowledgeable scientist to get a reasonable sense of the product. Is there demonstrated activity in an animal model for at least one exemplar from the project? Yes No If the product is therapeutic or preventative, is the mechanism of action known? Yes No Do you believe you are likely to have freedom to operate around the technologies required for your product? Yes No Under Evaluation Don’t know How we protect your informationYour personal details are incredibly important and we promise to use them to get in touch with you in the ways you prefer. We’ll never sell or swap your data and while, with your permission, our team may call, email or text you from time-to-time to thank you and encourage you to keep supporting our work, we will always do so with care and consideration.If you’d like to change how we communicate with you, or would like us to remove your details from our records, please email us at contact@developer.rnid.org.uk or call 0808 808 0123.For further details on how we look after your information, please read our privacy policy.Confirm your consent(Required) I consent to RNID collecting, using and storing my personal information as described in the privacy policy Please confirm you consent to RNID collecting, using and storing my personal information as described in our privacy policy. We would love to keep you up to date with the work we do, including Hearing Therapeutics Initiative activities and the latest developments in the field. Would you like to receive the quarterly HTI eNewsletter in future?Email newsletter Yes No Would you like to be contacted about joining special interest working groups and contributing to events focused on hearing therapeutic development?Special interest groups opt-in Yes No Page last updated: 21 June 2022