ࡱ>  0+:bjbjR(R( >0B~_0B~_e1Z Z 8;| ; ; ; ; ; ; ; ;$^>A/;a"/;D;v8 ; ;6Y9y7:Z;0;7A A4Y9Y9Am9/;/;;AZ e:  REPORT OF INVENTION Confidential When completed, the Report of Invention is an important legal document. Care should be taken in its preparation. Information contained in this document is maintained in confidence and will not normally be disclosed to others except with the appropriate safeguards. In order to help us preserve patent rights please keep us appraised of your publication plans. Submission of a Report of Invention does not insure that a patent application will be filed. Ĵý reserves the right in its sole discretion to determine those Reports of Invention upon which it will seek patent protection. Inventorship is defined under U.S. patent law. Identification of a person as an Inventor in this Report of Invention does not assure he or she will qualify as an inventor under applicable law. 1. INVENTION TITLE________________________________________________________________________ 2. SUBMITTER ______________________________________________________________________________ Printed name of inventor to whom routine communications should be addressed 3. BRIEFLY SUMMARIZE THE INVENTION HERE. POINT OUT ITS NOVEL FEATURES AND ADVANTAGES OVER EXISTING TECHNOLOGY. ________________________________________________________________________________________________ _____________________________________________________________________________________________ ______________________________________________________________________________________________ _______________________________________________________________________________________________ ______________________________________________________________________________________________ _______________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ______________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _______________________________________________________________________________________________ 4. USE ADDITIONAL SHEETS TO PROVIDE A COMPLETE DESCRIPTION OF THE INVENTION WHICH SHOULD COVER THE FOLLOWING POINTS: a. general purpose or utility b. brief description of the state of the art c. technical description including drawings, schematics, sketches, etc. d. advantages and improvements over existing methods, devices or materials e. commercial applications 5. INVENTORS If there are more than two inventors, please append a copy of this page to list additional inventors. I (We) hereby agree to assign all right, title and interest to this invention to Ĵý and agree to execute all documents as requested, assigning to Ĵý our rights in any patent application filed on this invention, and to cooperate with Ĵý in the protection of this invention. Inventors Signature Inventors Signature Print Name Print Name Title Title College and Department College and Department Building and Room Building and Room Box Number Box Number Work Telephone Work Telephone Work Fax Work Fax Work Email Work Email Home Address Home AddressHome City, State and Zip Home City, State and Zip Home Telephone Home Telephone Faculty or Staff ID Number Faculty or Staff ID Number Country of Citizenship Country of Citizenship Employer Information (check all that apply): ___ Full-time employee of Ĵý ___ Ĵý student ___ Hold a dual paid appointment with another institution ___ Non-Ĵý employee ___ Visiting Scholar Employer Information (check all that apply): ___ Full-time employee of Ĵý ___ Ĵý student ___ Hold a dual paid appointment with another institution ___ Non-Ĵý employee ___ Visiting Scholar Please note that both Faculty/ Staff ID Number and country of citizenship are required; absence of this information may hinder distribution of inventors share of any royalties that may result from this technology. 6. FOR ANY INVENTOR LISTED ABOVE WHO IS EITHER EMPLOYED ON A FULL OR PART-TIME BASIS BY ANOTHER ORGANIZATION, PLEASE IDENTIFY THE OTHER EMPLOYER. The University reserves the right to separately reach agreement concerning revenue sharing with the person or entity that it determines has an ownership interest. Please append a copy of this page to list additional entries. Print Name Print Name Title Title Employer Employer Business Address Business Address Business City, State, Zip Business City, State, Zip Work Telephone Work Telephone Work Fax Work Fax Work Email Work Email  7. OWNERSHIP INFORMATION In the opinion of the inventor(s), this invention: ___ was developed at Ĵý in connection with my (our) regular job duties and therefore belongs to Tech under it Intellectual Property Policy. ___ was developed wholly or partly at one or more other institutions other than Ĵý, and therefore may be owned or co-owned by these institutions. (Please refer to section 6 above.) ___ was developed independent of Ĵý or any other institution and I (we) __________________________ wish to retain ownership and hereby request a letter from Tech confirming that Tech asserts no ownership interest. Please attach documentation showing basis of your ownership claim. 8. SUPPORT. A. Funding Support List the funding sources(s) for the project under which this invention was made. If applicable, please identify the governmental (e.g., NSF) grant or contract number and name of the Principal Investigator/Supervisor of each. (Do not list any funding sources gratuitously.) Funding Source/Sponsor Grant or Contract Number PI/Supervisor ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ B. Other Support If proprietary materials (e.g., cell line, antibody, plasmid, chemical compound) obtained from outside your laboratory was used to develop this invention under a restrictive written agreement (other than a normal purchasing agreement) such as a material transfer agreement, please attached a copy or summary of that agreement. In making this discovery did you utilize materials that were sent under the terms of a Material Transfer Agreement? YES ____ NO____ Provider Description of the Material Supplied ____________________________________________________________________________________________ ____________________________________________________________________________________________ 9. INVENTION RECORD When did you first conceive of the invention? ______________________________________________ What is the date of the first written record? ________________________________________________ Identify the document in 8 B above. ______________________________________________________ When did you first successfully test this invention? __________________________________________ 10. INVENTORS DISCLOSURE RECORD Have you disclosed the invention to individuals outside of Ĵý who is not a co-inventor? YES _______ NO _______ If so: To whom? ________________________________________________________________________________ When and where? __________________________________________________________________________ Orally or in writing? _______________________________________________________________________ Was a secrecy agreement signed prior to disclosure? _____________________________________________ B. Have you ever publicly disclosed the subject matter orally; in a printed paper or abstract; or electronically via the Internet or an electronic publication? YES _______ NO_________. If so, please list references and attach a copy of each such disclosure: _________________________________________________________ _______________________________________________________________________________________ Has a thesis or dissertation describing the invention been shelved in a library at Ĵý Tech or elsewhere? YES _____ NO ______ Where? _____________________________________________________________ Date of Publication: _______________ Students Name: __________________________________________ Title: ___________________________________________________________________________________ Have you submitted a manuscript for publication or abstract for presentation at a conference? YES ______ NO _______ If yes, give details including the actual or planned date of submission. If a manuscript has been accepted, give anticipated publication date and name of journal. Append a copy of the latest draft of the manuscript available. If the abstract has been accepted, give name and date of conference as well as anticipated date of publication of the abstract. ______________________________________________ _________________________________________________________________________________________ ________________________________________________________________________________________ E. Do you plan on submitting a manuscript for publication, abstract for presentation at a conference, or making any other public disclosure regarding the invention? YES _______ NO _______ If yes, give the anticipated date (at least month/year) for submitting the manuscript or making the public disclosure. _______________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 11. RELEVANT LITERATURE Identify any references, patent applications, or other publications of which you are aware and which you believe to be pertinent to this invention. Please attach a copy of each reference, if available. ________________________________________________________________________________________________ ________________________________________________________________________________________________ ______________________________________________________________________________________________ ________________________________________________________________________________________________ 12. COMMERCIAL POTENTIAL A. Indicate the commercial product, process or product improvement that could result from your discovery. ______________________________________________________________________________________________ ________________________________________________________________________________________________ _______________________________________________________________________________________________ B. Please provide a list of any companies that might be interested in this technology and contact information if known. ______________________________________________________________________________________________ _______________________________________________________________________________________________ ______________________________________________________________________________________________ 13. WITNESS This report of invention should be witnessed at the earliest date by someone within Ĵý who is not a co-inventor and who is technically qualified to understand the subject matter. 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