Pharmaceutical Technology Assessment Form
Please complete this form to provide a comprehensive evaluation of a pharmaceutical technology.
General Information
Full Name of Assessor
*
First Name
Last Name
Organization / Institution
*
Email Address
*
example@example.com
Technology Name
*
Brief Description of the Technology
*
Stage of Development
*
Please Select
Discovery/Research
Preclinical
Clinical Trials - Phase I
Clinical Trials - Phase II
Clinical Trials - Phase III
Approved/Marketed
Other
Intended Use / Indication
*
Assessment Criteria
*
Rows
Poor
Fair
Good
Very Good
Excellent
Clinical Efficacy
1
2
3
4
5
Safety Profile
6
7
8
9
10
Cost-Effectiveness
11
12
13
14
15
Regulatory Status
16
17
18
19
20
Implementation Feasibility
21
22
23
24
25
Please rate the overall potential of the technology.
*
1
2
3
4
5
Are there any major concerns or limitations identified?
*
No major concerns
Yes (please specify below)
If yes, please specify concerns or limitations.
Additional Comments or Recommendations
Submit Assessment
Should be Empty: