Complete this form to register and confirm your eligibility for this challenge of the United States Department of Health and Human Services (HHS). The challenge seeks research that enhances healthcare competition, expands patient choice, lowers costs, and improves health outcomes.

Complete Sections 1 and 2, the applicable individual, team, or entity section, and Section 6. Each additional team member or entity participant completes a separate copy of Section 7. An asterisk (*) indicates a required response within an applicable section. Click each field to enter text and each box to select it. Select one option for each multiple-choice question.

Section 1 Submission information

Submission title *

Challenge phase *

☐  Phase 1 AHRQ Research Proposals

☐  Phase 2 AHRQ Awards

For Phase 2 only, identify the Phase 1 winning submission *

Required for Phase 2. Only participants selected to receive a Phase 1 prize may participate in Phase 2.

Briefly describe how your proposed research advances the challenge objectives *

Identify the policies or issues to be studied and the intended effects on competition, patient choice, costs, or health outcomes.

I am registering as *

☐ INDIVIDUAL  On behalf of myself. Complete Section 3.

☐ TEAM  A group of individuals, not an established organization. Complete Section 4.

☐ ENTITY  A legally established organization, institution, or corporation. Complete Section 5.

Section 2  Funding and eligibility

All registrants complete this section. The eligibility and participation rules in the official challenge announcement govern participation in this challenge. Registration alone does not establish eligibility or guarantee an award.

Have you used, or do you intend to use, federal grant or cooperative agreement funds to develop this submission or support it? *

☐ Yes

☐ No

Have you used, or do you intend to use, federal contract funds to develop this submission or support it? *

☐ Yes

☐ No

If either answer is Yes, stop. The attached challenge announcement prohibits these uses of federal funds for all registration types, including entities. Contact the challenge administrator before proceeding.

Eligibility Certifications

Review and confirm each statement below by checking its box. Each is required. If any statement cannot be confirmed, contact the challenge administrator before proceeding.

☐ The registrant is not a federal entity. No participant is a federal employee acting within the scope of federal employment.

☐ No participant is an HHS employee, including an employee of any HHS component, acting in a personal capacity.

☐ Each participant employed by a federal agency outside HHS has consulted an agency ethics official and obtained written confirmation of whether federal ethics rules limit or prohibit accepting a prize. If no participant has such employment, this condition does not apply.

☐ No participant is a challenge judge or a party involved in the design, production, execution, or distribution of this challenge. No participant is an immediate family member of such a party: spouse, parent, stepparent, child, or stepchild.

☐ Each individual participating will be at least 18 years old at the time of submission.

☐ I understand that the citizenship or permanent residency requirement applies to individual and team registrants. A private entity must be incorporated in, and maintain its primary place of business in, the United States. I will complete the applicable certification in Section 3, 4, or 5.

Federal facilities or consultation with federal employees do not alone make a participant ineligible if made available to all participants on an equitable basis. Prize money from one phase may be used toward a future phase as described in the announcement.

Section 3 Individual Information

Complete this section only if registering as an INDIVIDUAL. Then complete Section 6.

First name *

Middle name (optional)

Last name *

City *

State or province *

Postal code *

Country *

Email address *

Phone number  (optional)

Include country code if outside the United States.

Organization or affiliation  (optional)

Individual certification

☐ I certify that I am a citizen or permanent resident of the United States. *

☐ I am registering on my own behalf, meet the challenge eligibility requirements, and agree to comply with the challenge rules. I understand that any prize awarded to me will be paid to me as an individual. *

Complete the participation agreement and signature in Section 6. Do not complete the team or entity sections.

Section 4  Team information

Complete this section only if registering as a TEAM. A team competes as a group of individuals, not on behalf of an established organization, institution, or corporation. Designate one eligible team leader to register, submit, and handle communications with HHS.

Team name *

Team leader first and last name *

Include middle name if applicable.

Team leader city *

Team leader state or province *

Team leader postal code *

Team leader country *

Team leader email address *

Team leader phone number  (optional)

Additional team members *

List each member’s full name, email address, role, and organization or affiliation. Do not list the team leader again. Each additional member completes Section 7.

Team leader certification

☐ I certify that I and every team member are citizens or permanent residents of the United States. *

☐ I am authorized to register and submit on behalf of this team. I certify that the team meets the eligibility requirements and agree to comply with the challenge rules. Each additional member must provide their own certification in Section 7. *

☐ I understand that all prize money for this team will be paid to me as the team leader. Division of the prize is at my discretion. HHS will not arbitrate, intervene, advise on, or resolve disputes among team members. *

Complete the participation agreement and signature in Section 6.

Section 5  Entity information

Complete this section only if registering as an ENTITY. The entity, rather than its point of contact, is the participant designated to receive any prize.

Full legal entity name *

Entity city and state or province *

Use the entity’s primary place of business.

Entity postal code and country *

Jurisdiction of incorporation *

For a private entity, enter the United States state or territory of incorporation. Otherwise, describe legal establishment.

Unique Entity Identifier (UEI)  (optional)

Encouraged, not required, under the announcement. Do not provide a tax identification number.

Point of contact

Point of contact first and last name *

Include middle name if applicable.

Point of contact job title or role *

Point of contact email address *

Point of contact phone number  (optional)

Additional entity participants  (optional)

If applicable, list each person’s full name, email address, job title, and organization or affiliation. Each additional participant completes Section 7.

Click or tap to enter your response.

Entity point of contact certification

☐ If this is a private entity, it is incorporated in, and maintains its primary place of business in, the United States. *

☐ I have authority to register on behalf of the entity. I certify that the entity meets the eligibility requirements and that both the entity and I agree to comply with the challenge rules. I agree that any prize for this entity will be paid to the entity identified above. *

Complete the participation agreement and signature in Section 6.

Section 6  Agreement and signature

The individual registrant, team leader, or authorized entity point of contact completes this section. Each additional participant signs Section 7. Read the official announcement, including its Eligibility, Participation, Prize Payment, and Other Rules, before signing.

Participation agreement

By signing, I acknowledge and agree to the following terms, as set out in the official challenge announcement:

I assume any and all risks and waive claims against the federal government and its related entities, except in the case of willful misconduct, for injury, death, damage, or loss of property, revenue, or profits arising from participation. The waiver includes direct, indirect, and consequential losses, whether arising through negligence or otherwise.

I warrant that I am the sole author or owner of, or have sufficient rights to use and improve, the works in the submission. The works are wholly original or improved versions of existing works that I have sufficient rights to use and improve. The submission does not infringe copyright or other third-party rights of which I am aware. There are no legal obstacles to granting the licenses required by the announcement.

I grant HHS an irrevocable, paid-up, royalty-free, nonexclusive worldwide license to reproduce, publish, post, link to, share, and publicly display the submission. I also grant the nonexclusive, nontransferable, irrevocable, paid-up worldwide license to practice, or have practiced for or on its behalf, the solution. I retain all other applicable intellectual property rights. Participation does not authorize use of HHS trademarks or imply federal endorsement.

I agree to comply with all challenge requirements and applicable federal, state, and local laws, regulations, and policies. If selected for a cash prize, I will submit all required winner verification and payment documents by the specified deadline. AHRQ will pay its prizes directly by electronic funds transfer. Prizes may be subject to federal income taxes.

I acknowledge the rights reserved to HHS under the announcement, including disqualification of submissions, cancellation, suspension or modification of the challenge, and withholding of prizes if no submissions are deemed worthy. HHS may grant or deny requests to update registration information.

☐ I have read, understand, and agree to comply with the full official challenge rules. I certify that the information in this registration is accurate and complete to the best of my knowledge. If signing for an entity, I confirm that I have authority to accept these terms on its behalf. *

Printed full name *

Signing capacity *

Individual registrant, team leader, or entity point of contact

Signature *

Insert signature using the accepted signing method.

Date signed *

Section 7  Additional participant certification

Each additional team member or entity participant completes and signs a separate copy of this section. The team leader or entity point of contact combines the completed copies with the registration packet. Do not sign for another person.

Submission title *

Team or legal entity name *

I am participating as *

☐  An additional team member

☐  An additional entity participant

First and last name *

Include middle name if applicable.

Email address *

Role or job title *

Organization or affiliation  (optional)

Participant certification

☐ I confirm that I meet the personal eligibility conditions in Section 2. If participating as a team member, I am a citizen or permanent resident of the United States. *

☐ I have read and agree to the participation agreement in Section 6 and the full official challenge rules, including the funding restrictions, risk waiver, and intellectual property licenses. *

☐ For a team, I understand that all team prize money will be paid to the named team leader, who decides its division. HHS will not resolve disputes among team members. For an entity, I agree that any prize money will be paid to the named entity. *

Signature *

Insert signature using the accepted signing method.

Date signed *

Click or tap to enter a date.