INTELLECTUAL PROPERTY DISCLOSURE

(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