PRIOR INFORMED CONSENT FORM

Prior Informed Consent Form

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Traditional Knowledge PIC
Technological Innovations and Ideas PIC

Traditional Knowledge PIC

Dear Traditional Knowledge holder(s),

The National Innovation Foundation (NIF) was established by the Department of Science and Technology, Government of India, in March 2000, as an autonomous society to recognise and promote grassroots innovations and traditional knowledge of individuals/communities. This initiative shall help in reducing the erosion of knowledge, increase the social esteem of the grassroots innovators and knowledge providers and help India become an innovative society. NIF strives to obtain the written consent and authorization from all the innovators/knowledge providers to disclose and/or add value to the innovation/traditional knowledge submitted for inclusion in the National Register of Green Grassroots Technological and Traditional Knowledge. An explanatory note has been enclosed along with this form to assist the innovators/TK holders to fill up the form. The note describes the implications of various options as indicated in the form. NIF assures full compliance with the conditions specified by you and any modification in these conditions will be taken up only after obtaining your written consent.


Reference No.: ______________________
Title of traditional/herbal practice: ______________________
We will appreciate if you could tick ‘YES’ or ‘NO’ in the appropriate blanks (for items A to E).	YES		NO

A. Can the NIF share your address with those interested in your innovation/idea?	_______		_______

B. Can the NIF display/publish your innovation/idea on the Internet/in Honey Bee magazine/other media?	_______		_______

C. Can the NIF share your idea/innovation under the following condition/situation (s)?
(a) (i) With partial disclosure/summary of your innovation	_______		_______
(ii) With full disclosure	_______		_______
(b) Only on commercial terms (if the interested party is willing to pay for it)	_______		_______
(c) At no cost for individual use, but permission required for commercial purpose	_______		_______
(d) After further research on it	_______		_______
(e) Any other option? Please specify: ____________________________

D. Can the NIF mediate on your behalf to pursue the following?
(i) Developing business plan by third party/students	_______		_______
(ii) Product development	_______		_______
(iii) Intellectual Property Right protection	_______		_______
(iv) Technology transfer to a third party	_______		_______

E. Would you like to share the benefits obtained through NIF/GIAN with a third party?
If yes, in what proportion out of 100, would you like to share the benefits with the following:

Innovator/TK holder	_______
Community/Village	_______
Innovation promotion fund	_______
Researchers or those who add value	_______
Institutional overheads	_______
Conservation of natural resources	_______

If you want to propose an alternative benefit sharing system, please advise:	_______

F. What kind of non-monetary benefits such as participation in exibition contact with other innovators or formal scientific expert will help further improve the scope of your innovation/traditional knowledge? _________________________________

G. Whether the consent of local community has been taken while submitting the traditional knowledge to NIF Yes / No / Does not arise

H. To what extent the specific traditional knowledge/community knowledge is known and / or practiced within or among the concerned communities ? Known to few / Known widely / Practiced widely

I. In the case of any improvement/modifications done by you in the existing knowledge, what way would you like to share the benefit ? Only community / Only communicator/ Both / Specify share

However, if the specific traditional knowledge / community knowledge is not public domain, the rights shall belong to the community represented by its leaders. Declaration : I /We have read this Prior Informed Consent Form and have understood the implications of various choices described in the explanatory note. I / We have voluntarily decided to select the option / options which I / We have ticked above for questions from A to F. I /We further assure NIF that all the information given above is true to the best of my / our knowledge and belief. I / We acknowledge that if the knowledge / innovation / practice contributed by me / us are already in public domain, then the restrictions in the form will not apply.

Name and Address of the Community/Traditional Knowledge Holder. ____________________________________________________________________________ ____________________________________________________________________________		--------------- (Signature)

Name of the Nominee / Authorised Representative: ____________________________________________________________________________ ____________________________________________________________________________		-------------- (Signature )

Name and Address of witness/Collaborator/Scout/NIF Representative. ____________________________________________________________________________ ____________________________________________________________________________ ----------------------- (Signature of witness) Date :____________		-------------- (Signature)

PRIOR INFORMED CONSENT FORM

Technological Innovations and Ideas

Dear Innovator (s)
The National Innovation Foundation (NIF) was established by the Department of Science and Technology, Government of India, in March 2000, as an autonomous society to recognise and promote grassroots innovations and traditional knowledge of individuals/communities. This initiative shall help in reducing the erosion of knowledge, increase the social esteem of the grassroots innovators and knowledge providers and help India become an innovative society.

NIF strives to obtain the written consent and authorization from all the innovators/knowledge providers to disclose and/or add value to the innovation/traditional knowledge submitted for inclusion in the National Register of Green Grassroots Technological and Traditional Knowledge. An explanatory note has been enclosed along with this form to assist the innovators/TK holders to fill up the form. The note describes the implications of various options as indicated in the form. NIF assures full compliance with the conditions specified by you and any modification in these conditions will be taken up only after obtaining your written consent.

Reference No.:                               ______________________

Title of traditional/herbal practice: ______________________

We will appreciate if you could tick ‘YES’ or ‘NO’ in the appropriate blanks (for items A to E). YES NO

A. Can the NIF share your address with those interested in your innovation/idea?
_______

_______

B. Can the NIF display/publish your innovation/idea on the Internet/in Honey Bee magazine/other media?
_______

_______

C. Can the NIF share your idea/innovation under the following condition/situation (s)?

(a) (i) With partial disclosure/summary of your innovation
_______

_______

(ii) With full disclosure
_______

_______

(b) Only on commercial terms (if the interested party is willing to pay for it)
_______

_______

(c) At no cost for individual use, but permission required for commercial purpose
_______

_______

(d) After further research on it
_______

_______

(e) Any other option? Please specify: ____________________________

D. Can the NIF mediate on your behalf to pursue the following?

(i) Developing business plan by third party/students
_______

_______

(ii) Product development
_______

_______

(iii) Intellectual Property Right protection
_______

_______

(iv) Technology transfer to a third party
_______

_______

E. Would you like to share the benefits obtained through NIF/GIAN with a third party?

If yes, in what proportion out of 100, would you like to share the benefits with the following:

Innovator/TK holder

_______

Community/Village
_______

Innovation promotion fund
_______

Researchers or those who add value
_______

Institutional overheads
_______

Conservation of natural resources
_______

If you want to propose an alternative benefit sharing system, please advise:
_______

F. What kind of non-monetary benefits such as participation in exibition contact with other innovators or formal scientific expert will help further improve the scope of your innovation/traditional knowledge?       _________________________________

Declaration : I /We have read this Prior Informed Consent Form and have understood the implications of various choices described in the explanatory note. I / We have voluntarily decided to select the option / options which I / We have ticked above for questions from A to F. I /We further assure NIF that all the information given above is true to the best of my / our knowledge and belief.

Name and Address Address of the Innovators

(Signature)

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Name of the witness/Collaborator/Scout/NIF Representative.

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

---------------------------

(Signature of witness)

Date :____________

National Innovation Foundation

Bungalow No 1, Satellite Complex, Jodhpur Tekra, Premchand Nagar Road, Ahmedabad - 380 015, Gujarat, India
email: info@nifindia.org, www.nifindia.org,Fax:+91-79-673 1903



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