GRASSP Licensing Application Form

GRASSP License Application Form

This application form must be filled out to obtaina license for the GRASSP Tests.

Step 1 of 10

IMPORTANT: A fully executed License Agreement must be in place before any use of GRASSP begins. Submission of this form does not constitute a license. Retroactive licensing is not available. All fields marked * are mandatory.

This application asks you to select the license category that applies to your intended use, disclose all funding sources and any commercial or regulatory involvement, and provide supporting documentation specific to your category.

Please read the License Category Selection step carefully before choosing a category: if your use could fall under more than one category, you are required to select the higher-tier category, and any possibility of future regulatory use — even if undecided — requires Category B.

Please complete this application in full. Incomplete applications will not be processed and will be returned to you. Processing time is 10–15 business days from receipt of a complete application, including all required supporting documents.

All fields marked with an asterisk (*) are mandatory. For questions about category eligibility, fee structures, or data sharing arrangements, contact NOCI before submitting your application, rather than after.

Questions: timryan@neuraloutcomes.com or Laura.Farran@uhn.ca

Your Name(Required)

Prefix First Last

Your Role in this project(Required)

Your Phone Number(Required)

Your Email Address(Required)

Enter Email Confirm Email

Legal Name of Organization(Required)

Operating Name if Different than Legal Name(Required)

Type N/A if the same as legal name

Organization Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Organization Type(Required)

Other Organization Type(Required)

Type of organization if you selected ‘Other’ in previous question

Recommended Category

C — Single-Payer Site

Based on your answers, your intended use appears to fall under this category (waived, subject to audit). This is because your organization operates within a publicly funded single-payer system with no patients charged, no commercial sponsor, and no research or regulatory involvement. Annual re-attestation will be required. Please confirm this category below.

Recommended Category

D — Multi-Payer Site

Based on your answers, your intended use appears to fall under this category (annual fee based on organization size). This is because your organization’s structure includes private, hybrid, or insurance-covered patients, or a for-profit entity, without a research, commercial sponsorship, or regulatory component. Please confirm this category below.

Recommended Category

A — Academic

Based on your answers, your intended use appears to fall under this category (USD $1,000 per study if data is shared, or USD $1,500 per study if data is not shared). This is because the sole output of this work is peer-reviewed publication, with no commercial sponsor, no regulatory submission, and no investigator financial interest. Please confirm this category below.

No Clear Match

Your answers don’t clearly match one of the four license categories based on the criteria above. This can happen with unusual or mixed-use situations. Please select the category you believe is the closest fit below, and describe your reasoning in the field that will appear. NOCI will confirm the correct category during review before any License Agreement is executed. If you’re unsure, contact NOCI directly before submitting: timryan@neuraloutcomes.com

Recommended Category

B — Clinical Trial / Commercial

Based on your answers, your intended use appears to fall under Category B — Clinical Trial / Commercial (USD $50 per administration, plus translation fees if applicable). This is because you indicated an industry-sponsored trial, a commercial or industry sponsor, potential regulatory use, or a financial interest held by the Principal Investigator or Clinical Lead. Please confirm this category below.

By typing your name below and clicking Submit, you agree that this constitutes your electronic signature and has the same legal effect as a handwritten signature. You confirm that you have the authority to bind your organization to the terms of this License Agreement, and you consent to conduct this transaction electronically.

Declaration of Intended Use

I have read and agree to the below Declaration of Intended Use

I, the undersigned authorized representative of the above-named organization, hereby declare that: The license category selected is accurate and complete as of the date of this application. All known or foreseeable uses of GRASSP data have been disclosed. All funding sources, commercial relationships, and conflicts of interest have been fully disclosed. Any use beyond the licensed category will require prior written approval from NOCI and may require payment of additional fees. NOCI will be notified in writing within 14 calendar days of any material change in scope, use, funding, sponsorship, patient volume, or regulatory intent. I understand that a knowingly false Declaration of Intended Use constitutes fraudulent misrepresentation, voids the license ab initio, and may result in statutory damages under the Copyright Act (Canada), R.S.C. 1985, c. C-42. An annual usage report will be submitted to NOCI by January 31st of each year, covering administration volume, use context, and any organizational changes in the prior calendar year. SIGNING THE GRASSP LICENSE APPLICATION FORM IMPLIES YOUR ACCEPTANCE OF THIS DOCUMENT AS A LEGAL CONTRACT between Neural Outcomes Consulting, Inc. (“NOCI”)/University Health Network (UHN) and you. This License Agreement shall be governed by the laws of the Province of Ontario and the federal laws of Canada. Any dispute shall be resolved in the courts of Ontario, Canada.

Full Name(Required)

Electronic Signature

Date Signed