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If you find anything in error, please contact Marc Nuar (

Application Information

Application Name:

Application Owner:

Application Technical Contact:

Application Support Model: 

Application Administration Model:

Application Description:

Application Marketplace ID/Link:

ServiceNow RequestDistribution Status & DateInternal Review Status & DateePHI IndicatorTarget User Base


Current Issues

List current issues here.  When an issue is resolved, document the resolution and date, and move the issue into the issue log.

Issue Log

Would it be helpful to maintain Maintain a list of issues and their resolution?.


Reapproval Conditions

Document the conditions under which the application would be subject to reapproval (e.g., collecting ePHI data when it did not previously).


Internal Review Status: complete or incomplete

Internal Distribution
Review Request DateOffice of Technology Transfer
ReviewLegal Counsel Review (if applicable)Marketing & Communications ReviewCompliance & Regulatory ReviewIT Security ReviewLITS HIPAA Security Review (if applicable)

Architecture Review (if applicable)



Upload collateral as it is collected.

Approval Artifacts

Upload approval artifacts as they are collected.  Approval artifacts and relevant documentation may be located here: (app Box folder link)

  1. Completed IP Disclosure.
  2. Commercial Evaluation Report.
  3. Legal Counsel Review.
  4. Marketing and Communications Review.
  5. Compliance and Regulatory Review.
  6. IT Security Review.
  7. Architecture Review.
  8. App Store Submission Templates.
  9. Distribution Review Checklist.