AHRQ Super Intelligence for Healthcare Improvement Initiative: Participant Registration Form
Complete this form to register for the Agency for Healthcare Research and Quality (AHRQ) Super Intelligence (SI) for Healthcare Improvement Initiative or to certify your participation in a registered team or entity.
Submit one primary registration per submission. Individuals register for themselves. A team leader registers for a team. An authorized point of contact registers for an entity. Each additional team member or entity participant must complete a separate additional participant certification using the same submission title and team or entity name. Do not sign or certify for another individual.
Read the official challenge announcement provided with this form. Registration does not replace the required challenge submission or establish eligibility or entitlement to a prize. The published challenge rules govern participation in the challenge.
*Indicates a required question within the sections that apply to you. Complete only the sections specified by your answers. Inquiries: See the point of contact in the official challenge announcement.
Registration Record
Primary registrants continue to Submission information. Additional participants go directly to Additional participant certification.
Registration Purpose *
Select one response.
☐ Primary entry registration
☐ Additional team member or entity participant certification
Submission information
For primary registrations only. After this section, continue to Federal funding.
Select the competition or track that best aligns with your submission. *
Select one response. Use a separate primary registration for each submission.
☐ Clinical Evidence Synthesis Transformation Challenge
☐ SI Tech Sprint Track A: SI for Healthcare Research
☐ SI Tech Sprint Track B: SI for Implementation Quality and Safety
Submission title *
Use this exact title on the challenge submission and on every related participant certification.
Briefly describe how your submission aligns with the selected competition or track. *
For either SI Tech Sprint track, identify the AHRQ data resource or measure you plan to use and explain its material role. For the evidence challenge, describe the proposed evidence synthesis capability.
Federal funding
Federal grant, cooperative agreement, and contract funds may not be used to develop or support a challenge submission. Registering as an entity does not create an exception.
Will federal grant, cooperative agreement, or contract funds be used to develop this submission or support related challenge activities? *
Select one response.
No: continue to Registration category. Yes: go to Federal funding restriction.
☐ No
☐ Yes
Federal funding restriction
Complete this section only if you answered Yes to the federal funding question. The challenge prohibits using federal grant, cooperative agreement, or contract funds to develop or support submissions. This response is not an eligible registration. If the actual funding plan changes to comply with the rules, submit a new primary registration with accurate answers.
Federal funding restriction acknowledgment *
Submitting this acknowledgment records the funding restriction only. It does not register an eligible entry.
☐ I understand that the stated funding plan does not meet the challenge rules.
Registration category
Complete the section for your registration category, then go directly to Participant certifications.
I am registering for this challenge as a(n) *
Select one response. Individuals go to Individual information. Team leaders go to Team information. Entity representatives go to Entity information.
☐ INDIVIDUAL: on behalf of myself
☐ TEAM: a group of individuals, not an established organization
☐ ENTITY: a legally established organization, institution, or corporation
Individual information
For individual registrants only. After this section, skip Team information, Entity information, and Additional participant certification. Continue to Participant certifications.
Last name *
First name *
Middle name
Phone number *
Email address *
City *
State or province *
Postal code *
Country *
Individual registration certification *
I am registering on my own behalf. I understand that any prize awarded to this individual registration will be paid to me. I agree to comply with the challenge rules.
☐ I agree and certify.
Team information
For the designated team leader only. After this section, skip Entity information and Additional participant certification. Continue to Participant certifications.
Team name *
Team leader last name *
Team leader first name *
Team leader middle name
Team leader phone number *
Team leader email address *
Team city *
Team state or province *
Team postal code *
Team country *
Additional team members *
List each additional member on a separate line: last name, first name, email address, job title or role, and organization or affiliation. Each listed person must separately complete Additional participant certification. This roster does not certify or sign for them.
Team leader registration certification *
I am the designated team leader and am authorized to register and submit for this team. I am responsible for communications with HHS. I understand that any team prize will be paid to the eligible team leader. Division of prize money among team members is at the team leader’s discretion, and HHS will not arbitrate or resolve disputes among team members. I agree to comply with the challenge rules.
☐ I agree and certify.
Entity information
For an authorized entity representative only. The point of contact (POC) is the lead individual participating for the entity. After this section, skip Additional participant certification and continue to Participant certifications.
Entity legal name *
Entity city *
Entity state or province *
Entity postal code *
Entity country *
POC last name *
POC first name *
POC middle name
POC phone number *
POC email address *
POC job title or role *
Additional entity participants
If applicable, list each additional participant on a separate line: last name, first name, email address, job title or role, and organization or affiliation. Each listed person must separately complete Additional participant certification. This roster does not certify or sign for them.
Entity point of contact registration certification *
I have authority to register and make these certifications on behalf of the entity named above. The entity is incorporated in and maintains a primary place of business in the United States. I understand that any entity prize will be paid to the entity. The entity and I agree to comply with the challenge rules.
☐ I agree and certify.
Additional participant certification
For each additional team member or entity participant, completed and signed by that person. This supplements the primary registration and does not create a separate entry. After this section, continue to Participant certifications.
I am participating as an additional *
Select one response.
☐ Team member
☐ Entity participant
Submission title *
Enter the exact title used in the primary registration.
Competition or track *
Select the same competition or track as the primary registration.
☐ Clinical Evidence Synthesis Transformation Challenge
☐ SI Tech Sprint Track A: SI for Healthcare Research
☐ SI Tech Sprint Track B: SI for Implementation Quality and Safety
Team name or entity legal name *
Enter the exact name used in the primary registration.
Team leader or entity point of contact email address *
Last name *
First name *
Middle name
Email address *
Job title or role and organization or affiliation *
Additional participant certification *
I am participating in the team or entity named above. I have read, understand, and agree to comply with the challenge rules. I understand that any team prize is paid to the eligible team leader and any entity prize is paid to the entity. I am submitting this certification for myself.
☐ I agree and certify.
Participant certifications
All eligible primary registrants and additional participants complete this section. Check each certification only if it is true and you agree. If you cannot make a required certification, do not sign or submit an eligible registration. Continue to Signature when finished.
Eligibility certification *
I certify that I meet the eligibility requirements applicable to my role:
• I will be at least 18 years old at the time of submission.
• I am not a federal employee acting within the scope of federal employment, and the registered entrant is not a federal entity.
• I am not an employee of HHS or any HHS component participating in a personal capacity.
• I am not a judge, a party involved in designing, producing, executing, or administering these challenges, or an immediate family member of such a party. Immediate family includes a spouse, parent, stepparent, child, or stepchild.
• If registering as an individual or participating as a team member, I am a United States citizen or permanent resident. This citizenship certification does not extend that requirement to an entity’s individual personnel.
• If registering an entity, it is incorporated in and maintains a primary place of business in the United States.
☐ I agree and certify.
Federal employment ethics certification *
Select one response. Employees of HHS or its components are not eligible to participate in a personal capacity.
☐ I am not employed by a federal agency or entity.
☐ I am employed by a federal agency or entity other than HHS, am participating outside the scope of federal employment, and have consulted an agency ethics official about any limits or prohibitions on accepting a prize.
Federal funds certification *
I will not use federal grant, cooperative agreement, or contract funds to develop the specific challenge submission or support my specific challenge activities. If I am the primary registrant, I also certify this for the registered submission. These costs will not be charged to a federal contract.
☐ I agree and certify.
Challenge rules agreement *
I have read the official challenge announcement provided with this form and agree to its rules and requirements. My statements are accurate and complete. I understand that eligibility, selection, and payment depend on satisfying the published requirements and completing any required winner-verification and payment documents. Registration alone does not constitute submission of an entry or guarantee a prize, contract, or adoption.
☐ I agree and certify.
Data use and scientific integrity agreement *
I agree to applicable privacy, security, accessibility, data-use, licensing, and scientific-integrity requirements. I will disclose material models, data sources, services, dependencies, and human assistance as required. If participating in an SI Tech Sprint track, the submission will make material, traceable use of an AHRQ competition data resource or measure. I will not attempt prohibited re-identification, disclose prohibited data, or transmit controlled AHRQ data to an external service without the required authorization. I will meet applicable training and data-use agreement requirements before accessing controlled data.
☐ I agree and certify.
Submission rights certification *
I own or have sufficient rights to use, modify, evaluate, and license the materials included in my contribution or, as an authorized entity representative, the entity’s submission. The submission is original or an improvement of work that the participant has sufficient rights to use and improve. It does not knowingly infringe copyright or other third-party rights. There are no legal obstacles to granting the government the licenses described below, within the rights I am authorized to grant.
☐ I agree and certify.
Written consent to government licenses *
As a participant, or as the authorized representative of the registered entity, I grant HHS an irrevocable, paid-up, royalty-free, nonexclusive worldwide license to reproduce, publish, post, link to, share, display, and evaluate the submission and challenge deliverables. I also grant a nonexclusive, nontransferable, irrevocable, paid-up license to practice, or have practiced for or on behalf of the government, the submitted solution for evaluation and governmental purposes described in the challenge announcement.
These licenses are limited to rights the participant is authorized to grant and remain subject to applicable protections for confidential commercial information and third-party rights. Participants retain other intellectual-property rights; transfer of ownership to HHS is not required.
☐ I expressly consent in writing to these licenses.
Assumption of risk and waiver of claims *
I agree to assume 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, whether direct, indirect, or consequential and whether arising through negligence or otherwise.
This waiver excludes claims arising from the administering agency’s unauthorized use or disclosure of a participant’s intellectual property, trade secrets, or confidential business information, as provided in 15 United States Code (U.S.C.) § 3719(i)(4). Any waiver of insurance, financial-responsibility, or indemnification requirements remains subject to an approved agency waiver under 15 U.S.C. § 3719(i)(3) and the published challenge rules.
☐ I agree and certify.
Signature
The individual registrant, team leader, authorized entity representative, or additional participant completing this response must sign personally. Submit the completed registration or certification through the official registration channel.
Signature full legal name *
Type your full legal name. For a paper copy, sign in this field.
Signature date *
Enter the date as YYYY-MM-DD (year-month-day).
Signature certification *
I certify that the information in this response is accurate and complete. I intend my typed name and this confirmation to serve as my electronic signature on the certifications and consents above. If signing for an entity, I have authority to bind that entity. I am not signing on behalf of other individual participants.
☐ I sign and certify.
