Section 1: Your details

Name *

Full name

Email *

Organisation name *

Product name *

Name of the IM1 product you are wanting to onboard with

Section 2: Clinical safety prerequisites

Confirm the following prerequisites are already in place:

A qualified Clinical Safety Officer is in place *

• Yes

A detailed use case description that covers the entirety of the product *

• Yes

A written clinical safety process and a commitment to uplift this as required with the development of the IM1 product *

• Yes

Ability to populate a detailed hazard log template and a commitment to uplift this as required with the development of the IM1 product *

• Yes

Confirm that if the product contains software as a medical device you understand that this would be subject to additional scrutiny *

• Yes

Section 3: Information governance prerequisites

Confirm you are committed to the following:

Starting the process of obtaining a Data Security and Protection Toolkit (DSPT) annual assessment, to be in place by time of go live *

• Yes

Completing a Data Protection Impact Assessment including Transparency/Privacy Notice for the consuming supplier and for associated applications and services as required for relevant use cases *

• Yes

Utilising an Information Security Management System (ISO 27001 recommended) *

• Yes

Completing a penetration test (pen test) which must be completed by a 3rd party CHECK / CREST accredited organisation, prior to go live and annually thereafter. The CHECK / CREST accredited organisation must be accredited to conduct penetration testing *

• Yes

A UK location for processing patient data *

• Yes

Section 4: Provider suppliers

Confirm which provider supplier(s) you would like to integrate with (you may select more than one):

EMIS (EMIS Web)

• Yes

TPP (SystmOne)

• Yes

Medicus

• Yes

Section 5: Use case and benefits

What will you use IM1 access for and how will it improve delivery of care? *

2000 character limit. Please state the clinical use case and summarise the release scope for the product, including the benefits to the NHS and patient clinical care.

Interface options

EMIS

• PFS
• Transaction
• Partner
• Bulk

TPP

• PFS
• Transaction
• Bulk

Other GP new market entrants as when available

• Medicus
• Other

If 'Other', please name the new market entrant

If using PFS, would you be utilising NHS Login as an authentication method for PFS?

• Yes
• No

Does your use case use artificial intelligence (AI)? *

• Yes
• No

If yes, how?

2000 character limit

Are the following documents to support your application to IM1 in a draft state?

Data Protection impact assessment (DPIA) *

• Yes
• No

Clinical safety case *

• Yes
• No

Hazard log *

• Yes
• No

Medical device status of certification (if applicable)

• Yes
• No

Please add any other supporting information you feel relevant

2000 character limit