CONFIDENTIAL

Invention Disclosure Form

This form is a way to let us know you have innovation or technology and give us basic information about it.

• We will contact you after we receive your questionnaire to ask any further questions we may have, and to explain the next steps.

• Answer each question by clicking a check box or by typing into the associated table or fillable box.

• If you are unsure how to answer a question, just leave it blank and we’ll talk to you about it later.

• We will keep you informed as we evaluate patentability, market potential and licensability, and we will discuss any decisions with you before they are made.

Date

First name

Last name

Phone

Position

Department

Provide A Brief Name of IP

Please provide a description of the invention. If you have one, please attach a manuscript or other document that describes the invention in more detail.

Is this invention disclosure related to any earlier invention disclosure here or at another institution?

Yes

If Yes, please describe. If another institution, please state.

How does the invention improve upon what was previously known in the field?

What products or services are made possible by the invention?

Please describe any competing approaches at any stage of development (e.g. existing commercial products or services, etc) that your invention may compete with.

Please list any companies you know of that might be interested in this invention.

Please list any publications or patents you know of that might be relevant to this invention.

Has any aspect of this innovation been publicly disclosed?

Yes

Do you have any plans to make a public disclosure in the next 30 days?

Yes

If so, when and where?

Has the research that led to the innovation been sponsored or funded by industry, or funded by a grant(s) from a government agency or private foundation?

Yes

If yes, disclose all funding sources and amounts

In this research did you use any materials or confidential information provided by another institution or company?

Yes

If yes, please disclose. If there is an MTA completed. Please attach to this disclosure.

If you do not currently have funding, are you actively seeking it?

Yes

Is there anything else you think we should know?

Are there any other inventors that are part of this innovation? Please list here.

File upload

Signature