Third Call for Reference Sites - Self-Assessment Questionnaire
EXTENDED DEADLINE UNTIL THE 15th JULY 2019!

The questionnaire below forms part of the evaluation process for the 3rd Call for Reference Sites. Please fill in the following data with relevant information about your Reference Site candidature.

For additional information about the Call and support on how to fill out this questionnaire, please consult the Call Information and Guidance document (https://ec.europa.eu/eip/ageing/library/3rd-call-reference-sites-information-and-guidance_en).

If you have any additional questions, you can consult the FAQ (https://ec.europa.eu/eip/ageing/library/3rd-call-reference-sites-frequently-asked-questions-faq_en) or send an email to we4aha@funka.com.

SECTION 1 ABOUT YOU
SECTION 1.1 ABOUT YOUR ORGANISATION
Leading organisation name *
Your answer
Contact name *
Your answer
Organisation's address *
Your answer
Contact email *
Your answer
Country *
Your answer
Please describe your organisation and core activities
Your answer
Name of Region, Municipality, City (or other territorial area)
Your answer
Number of inhabitants in the Region, Municipality, City (or other territorial area)
Your answer
Population coverage
Number of ageing people 65-79
Your answer
Number of ageing people 80+
Your answer
Number of ageing people 65+ (with long term chronic conditions)
Your answer
Relevant indicators
Health and care workforce (FTE equivalent)
Your answer
Cumulative budget (€) invested in deployment and implementation of innovative solutions for active and healthy ageing (period 2016 - 2018):
Your answer
- Number of patients / citizens benefiting from the deployment of these innovative solutions (see previous question):
Your answer
Cumulative budget (€) invested in deployment and implementation of innovative solutions for active and healthy ageing (period 2019 - 2021):
Your answer
- Number of patients / citizens benefiting from the deployment of these innovative solutions (see previous question):
Your answer
SECTION 1.2 YOUR COALITION PARTICIPATION IN THE EIP ON AHA PARTNERSHIP
Have you been awarded Reference Site status before?
If yes, please indicate the number of stars awarded
Please list any EIP Action Group Commitments that you plan to submit for the 2019 Call for Commitments (September 2019).
Your answer
Please identify in which Action Group/s the Reference Site will be actively participating during the period 2019-2021.
SECTION 1.3 DIGITAL INNOVATION HUBS (DIH)
Do you have a DIH related to health and care in your region or geographic area?
- If YES, what kind of DIH and thematic area of health and care are you interested in?
Your answer
- If NO, are you planning to develop a DIH for health and care in your region?
SECTION 1.4 EIP ON AHA CONFERENCE OF PARTNERS
Have you ever attended the EIP on AHA Conference of Partners?
Will you attend the next EIP on AHA Conference of Partners that will be organised in the framework of the AAL Forum the 23-25 September in Aarhus, Denmark?
If you are awarded as Reference Site, will you attend the Award Ceremony that will be organised on the 25th of September in the evening?
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