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Health Technology Assessment

Health Technology Assessment Topic Proposal Form

Requestor Information


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Organization *
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Date Information Required


Please specify the type of intervention (drug or health technology) for which the assessment is requested.
Drugs Devices Procedures Health System
IMPORTANT: Please note these interventions need to be used for direct patient care in order to be considered for assessment.

Please specify the type of organization that will be funding this intervention.
Ministry Regional Hospital
Other (please specify):

Specific information

1. Please describe the intervention requiring assessment. (e.g., Sevelamer hydrochloride oral tablets, 64-slice CT Scan)

2. Please specify the setting for the intervention (i.e., where is this intervention accessed and under who's authority?).(e.g., hospital ward through pharmacist, emergency department by ED physician, patient's home through GP, etc)

3. Please specify why there is a need to assess this intervention (select all that apply).
Potential clinical benefits (e.g., reduced number of heart attacks, strokes, or emergency room visits) Potential non-clinical benefits (e.g., improved patient satisfaction, shorter hospital length of stay) Utilization pattern (e.g., current use is a deviation from recommended use, inconsistent use) Budget impact on health care system Potential harm issues Ethical issues
Other (please specify)

4. Please provide information on the following to further define the research question.
Patient Group (i.e., condition being investigated or treated, gender, age, particular subgroups of patients being targeted)

Comparators (i.e., standard of care, alternative technology or drug)

Outcomes of Interest

5. Please specify current policy surrounding funding of this intervention or its alternatives.(e.g., funded by unique fee code, funded by alternative fee code, not funded, fully funded, or under restricted conditions)

6. Please describe future policies that are being considered regarding this intervention.(e.g., funded by unique fee code, funded by alternative fee code, not funded, fully funded, or under restricted conditions)

7. Please describe the anticipated impact of a policy change about this intervention on the provision of care and on the health care system. (e.g., shorter hospital length of stay, increased drug expenditures)

8. Please identify any other key stakeholders who may be affected by any policy change about this intervention.

9. Please provide any further comments that may help to refine your topic proposal.


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