(Attach additional sheets as
appropriate)
I. DESCRIPTIVE TITLE OF INTELLECTUAL PROPERTY
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
II. PRIMARY INVENTOR
1.___ Name: _______________________________________________
Last First MI Degree
2. Social Security Number: ___________________________
3. School and Program: ___________________________
4. Campus Mail: ___________________________
5. Campus Phone Number: _____________ Fax Number: ______________
6. Home Address: _______________________________________
Street
_______________________________________
City State Zip
7.___ Home Phone Number: ( ____ ) ____________________
8.___ Percent of time employed at University ______________
9.___ Other employment, if any ________________________________________________
____________________________________________________________________
10.__ How much time was spent by you personally in making this invention? ______________
____________________________________________________________________
11. Approximately what percentage of the overall invention was created by you? (Note: Percentage (%) created by you plus all co-inventors cannot exceed 100% in total.)
_______________
12.__ Signature: ____________________________________ Date: __________________
____ Typed or Printed Name: ________________________________________________
III. ADDITIONAL INVENTORS (Use a separate page(s) for each additional inventor)
1.___ Name: _______________________________________________
Last First MI Degree
2. Social Security Number: ___________________________
3. School and Program: ___________________________
4. Campus Mail: ___________________________
5. Campus Phone Number: _____________ Fax Number: ______________
6. Home Address: _______________________________________
Street
_______________________________________
City State Zip
7.___ Home Phone Number: ( ____ ) ____________________
8.___ Percent of time employed at University ______________
9.___ Other employment, if any ________________________________________________
____________________________________________________________________
10.__ How much time was spent by you personally in making this invention? ______________
____________________________________________________________________
11. Approximately what percentage of the overall invention was created by you? (Note: Percentage (%) created by you plus all co-inventors cannot exceed 100% in total.)
_______________
12.__ Signature: ____________________________________ Date: __________________
____ Typed or Printed Name: ________________________________________________
IV. INVENTION INFORMATION
1. BRIEFLY SUMMARIZE THE PURPOSE AND USE OF INVENTION.
2. DESCRIBE THE COMMERCIAL APPLICATION OF THE INVENTION, POTENTIAL MARKETS AND ANY SPECIFIC INDUSTRY OR BUSINESS CONTACT PERSONS WHO MAY BE INTERESTED IN THIS INVENTION.
3. WHAT PARTICULAR FEATURES OF THIS INVENTION ARE NOVEL?
4. HOW DOES THIS INVENTION DIFFER FROM PRESENT TECHNOLOGY?
5. HAS THE INVENTION BEEN, OR WILL BE, DISCLOSED IN ANY PRINTED PUBLICATION? YES ______, NO _______
If Yes, identify the publication and date.
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6. DATE INVENTION WAS 7. DATE INVENTION WAS FIRST
CONCEIVED. DISCLOSED TO OTHERS.
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8. TO WHOM WAS INVENTION 9. DATE THE FIRST DRAWING
DISCLOSED? OR SKETCH WAS MADE.
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10. DATE OF THE FIRST 11. DATE FIRST CONSTRUCTION
WRITTEN DISCLOSURE. OR MODEL WAS MADE.
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12. HAS THE INVENTION BEEN TESTED? YES ______, NO _______
IF YES, STATE DATE OF FIRST TEST AND DESCRIBE THE RESULTS.
13. HAS THE INVENTION BEEN USED?
YES ( See below ) _______, NO _______
YES, EXPERIMENTALLY (State date and details)
YES, ROUTINELY (State date and details)
14. WAS THE DEVELOPMENT OF THE INVENTION AIDED IN ANY WAY BY A GRANT OR CONTRACT?
YES ______
NO _______ If no, omit question numbers 15 and 16.
15. TITLE OF GRANT OR CONTRACT (If more than one, list each separately).
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
SPONSOR NUMBER ____________________
UTA ACCOUNT NO. ____________________
AGENCY ___________________________________________________________
____________________________________________________________________
____________________________________________________________________
16. BRIEFLY DESCRIBE THE PURPOSE OF THE GRANT OR CONTRACT AND HOW DEVELOPMENT OF THE INVENTION WAS AIDED.
17. EXPLAIN BRIEFLY THE USE, IF ANY, OF THE FOLLOWING ITEMS IN CONNECTION WITH THE MAKING OF THE INVENTION.
A. THE USE OF UNIVERSITY FACILITIES, LABORATORIES, OFFICES, ETC.
B. THE USE OF UNIVERSITY EQUIPMENT (such as instruments, tools, or machinery).
C. THE USE OF UNIVERSITY MATERIALS (supplies, reagents, parts, or any other materials; if scrap, waste or salvage materials were used, so state; give estimated monetary value of materials consumed).
D. AMOUNT OF UNIVERSITY FUNDS, OTHER THAN SALARIES AND WAGES, WHICH WERE ACTUALLY OBLIGATED OR EXPENDED FOR THE PURPOSE OF MAKING INVENTION.
E. CONTRIBUTION OF TIME OR SERVICES OF OTHER UNIVERSITY EMPLOYEES (state approximate number of hours and type of assistance).
18. DESCRIBE A SPECIFIC EMBODIMENT OF THE INVENTION (include sketch, drawings, circuit diagrams, photographs, chemical formulas).
19. ITEMIZATION OF DOCUMENTS BEING ATTACHED TO THIS DISCLOSURE:
20. TWO WITNESSES SHOULD SIGN BELOW IN SPACES INDICATED:
1) Witness: ______________________________________ Date: ________________
signature month/day/year
2) Witness : _____________________________________ Date: ________________
signature month/day/year
IMPORTANT: Once this disclosure has been signed by the inventor(s) (see sections I and II) and witnesses (see section IV - subsection 20 above), no changes should be made in the description or drawings. All additions or corrections should be submitted in the form of a supplemental memorandum particularly referencing this disclosure or in the form of a new disclosure.
PLEASE NOTE: If funding for project comes from any part of the Department of Defense, the attached form must be filled out. DOD FORM 882