Part I/IV - Third Call for Reference Sites - Self-Assessment Questionnaire
EXTENDED DEADLINE UNTIL THE 16th DECEMBER 2019!

The questionnaire below forms part of the evaluation process for the extension of the 3rd Call for Reference Sites. Please fill in the following data with relevant information about your Reference Site candidature. In order to facilitate the work, the form has been divided into four separate sections which can be saved individually.

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/extended-3rd-call-reference-sites-information-and-guidance-pack_en).

If you have any additional questions, you can consult the FAQ (https://ec.europa.eu/eip/ageing/library/extended-3rd-call-reference-sites-frequently-asked-questions-faq_en) or send an email to we4aha@funka.com.
Email address *
SECTION 1 ABOUT YOU
SECTION 1.1 ABOUT YOUR ORGANISATION
Reference Site name *
Your answer
Leading organisation name *
Your answer
Contact name *
Your answer
Leading organisation's address *
Your answer
Contact email *
Your answer
Country *
Your answer
Please describe your organisation and core activities (Max. 3,000 characters) *
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
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? *
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