Tangible MaterialDisclosure Form

Tangible Material Disclosure Form

Thank you for disclosing your invention to KU Innovation and Collaboration (KUIC).We will confidentially review the materials that you provide us. Welook forward to working with you to facilitate the translation of your new discovery into a commercial product/process. We are here to help in any way – please contact us with any questions you may have.

-- KUIC Staff

Rev. 11/2017

Instructions
Why submit an Invention Disclosure Form: /
  • Completion of the Tangible Material Form is the first step in the commercialization process and supplies KUIC with the necessary information to begin assessing the invention.
  • All federal funding sources and most other funding sources require invention reporting, and this document will facilitate KU’s compliance with those obligations.
  • The KU IP Policy governs the disposition of all IP created or authored by faculty, staff and students.

How to complete the Invention Disclosure Form: /
  • Complete the form by typing directly in the text boxes.
  • Create a Title to identify the Material(s). Enter it in the space provided in Parts I, III and IV
  • When complete, print the form.
  • Prior to submitting to KUIC, each inventor must:
  • Complete and sign anInventor page
  • Review and sign the Assignment of Rights in Part IV (KU Inventors only)
*KU inventors include all inventors at KU at the time of creation of the invention.
Where to send the form once it is completed: /
  • Scan the completed form and email it to . If you have been in contact with one of our licensing staff, please note that person’s name in the email.
OR
  • Mail your completed form with all signatures to 2385 Irving Hill Road, Lawrence, KS 66045

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Tangible MaterialDisclosure Form

Part I: Invention Information
Title:
Name of the Material(s): / Click here to enter text.
Previous Invention:
Is the Material related to a previous invention disclosed to KUIC? / Yes☐ No☐
Invention Description:
Type of materials(e.g. Antibody, Mouse, Cell Line, Plasmid, etc.): / ☐Antibody – Monoclonal ☐Antibody – Polyclonal
☐Protein/Peptide ☐Animal Model
☐Other Tangible
Provide a brief description of the Materials being disclosed:
(Please also attach any supporting information, such as a summary, PowerPoint, grant applications, draft manuscripts or abstracts that describe how to make and use your invention in sufficient detail so that someone in your field can make and use the invention just by reading the description.) / Click here to enter text.
Biological Material Detail:
Antibody / ☐Monoclonal (answer question 1-10 below)
☐Polyclonal (answer questions 3-11 below)
Clone: / Species:
Immunogen: Please describe species, amino acids included, protein tags, other modifications / Click here to enter text.
Hybridoma: Species immunized, myeloma parent, clone number, produced as / Click here to enter text.
Antigen/epitope recognized / Click here to enter text.
Immunoglobulin isotype / Click here to enter text.
Species reactivity / Click here to enter text.
Purification method / Click here to enter text.
Concentration:Click here to enter text. / How is concentration measured?Click here to enter text.
Please list optimal concentrations for applications tested. / Click here to enter text.
Amount available / Click here to enter text.
Species immunized
Protein/Peptide
Name(s) of protein/peptide / Click here to enter text.
Describe the protein sequence: amino acids included, protein tags, other modifications, molecular weight / Click here to enter text.
Origin/Purification method / Click here to enter text.
Purity/Form/Storage conditions / Click here to enter text.
Animal Model
Name of model in standard nomenclature / Click here to enter text.
Background strain(s) / Click here to enter text.
Targeted gene(s) / Click here to enter text.
Genotype details (transgenic, targeted mutation, inducible) / Click here to enter text.
Tell us how the strain was produced and the origin of the materials used. / Click here to enter text.
Describe the phenotype observed / Click here to enter text.
Are breeding pairs available? / List any special housing requirements.Click here to enter text.
Other Tangible Materials (Such as Cell Line/Reagent/Chemical/Plasmid/Engineering Material)
Describe the material, how it was created, and the amount available / Click here to enter text.
Establishment of Material History: / Please provide your best estimate for the date when the following occurred (or will occur):
Provide date the Material was created / Date: Click here to enter text. Has this date been documented? If so, where? Click here to enter text.
Amount of the Material that is available / Click here to enter text.
Has the Material been described either in a publication(e.g. in an abstract, poster, manuscript, website, or powerpoint) or verbally disclosed(e.g. in a presentation, talk, or meeting with industry)to the public(i.e. to. those outside of the KU community)?

If yes, please attach any files that contain the disclosure material and list where and when you disclosed. / Please include names of periodicals/journals/conferences.
Where:Click here to enter text. Date: Click here to enter text.
Where:Click here to enter text. Date: Click here to enter text.
Where:Click here to enter text. Date: Click here to enter text.
Where:Click here to enter text. Date: Click here to enter text.
If unpublished and undisclosed, provide the anticipated publication or public oral disclosure date and any submissions made for potential publication. / Where:Click here to enter text. Date: Click here to enter text.
Where:Click here to enter text. Date: Click here to enter text.
Commercialization Potential:
Have you received requests for the Material? How many, approximately? Commercial requestors? / Click here to enter text.
List any element or features of the Material that you believe to be novel or unique: / Click here to enter text.
What are the advantages of the Material versus present technologies? How is the material different from and superior to existing materials? / Click here to enter text.
List the likely potential therapeutic application area(s) for this Material: / ☐Analgesic ☐Cardiovascular ☐Infectious Disease
☐Developmental Biology/Stem Cell ☐Inflammatory/Immune
☐Metabolic Disorders ☐Neuroscience ☐Oncology
☐Ophthalmology ☐Research Reagent ☐Engineering Material
☐Other Click here to enter text.
Is the Material derived from human tissue or samples? Please explain briefly. / Click here to enter text.
Describe the current developmental stage of the Material (e.g. conceptual, tested in experiments or computer simulations, working prototype, etc.) ? / Click here to enter text.
Is work on the Material continuing? If there is more work to be done, please indicate the nature of the work to be done and how long it will take to complete, whether the necessary resources to do the work are available, and the milestone(s) that would trigger commercial interest. / Click here to enter text.
Commercialization Contacts: / List any potential licensees (e.g. companies, investors, or entrepreneurs) that may be interested in commercializing the Material. Please attach additional sheet if more space is required.
Company Name / Contact Person / Contact Information
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.
Part II: Reporting
Funding Information: If you received full or partial support during any stage of your research resulting in theTangible Property, or if you have acknowledged or plan to acknowledge a funding source in a publication or grant progress report in which you describe the invention, please indicate all source(s) of your funding by checking the appropriate box or boxes below. If you were not funded, please check none.
☐Federal ☐Foundation ☐Industry ☐State ☐Other ☐None
Please identify below each funding source’s name and each corresponding grant, contract or award number/ID.
Funding Source Name
(List primary funding source first) / Grant/Contract/Award Numbers/IDs
(Please do not list cost center numbers) / Principal Investigator
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.
Third Party Material:Was any material or equipment provided by a third party? /
If yes, please provide details: / Click here to enter text.
If yes, was a material transfer agreement signed? / Yes☐ No☐
Indicate the material and from where you received the material: / Click here to enter text.
Export Control: Didthe research resulting in the invention have any of the following characteristics?
  • "Dual use" (commercial in nature with possible military application) or inherently military in nature
  • Remote sensors, lasers, micro-electronics
  • Geological surveying using advance electronics and software
  • Bio-technology development
  • Aerospace engineering
  • Advanced computing
  • Controlled chemicals, biological agents, and toxins:
For additional information check
If “Yes” please explain:
If you answered “yes”, do any of the following occur?
  • a physical transfer/disclosure of an item outside the U.S.
  • any transfer/disclosure of a controlled item or information within the U.S. to a foreign national
  • participation of foreign national faculty, staff, or students who requires access to controlled technology
  • presentation/discussion of previously unpublished research at conferences or meetings where foreign national scholars may be in attendance
  • research collaborations with foreign nationals and technical exchange programs
  • transfers of research equipment abroad
  • visits to your work areas by foreign nationals
If “Yes” please explain:
Contact the KUIC for additional information
Note: There are number of projects that might be subject to export control following are some examples:(1) international collaboration which may involve export of goods, technology or technical data; (2) commercial and military application; (3) remote sensors, lasers & micro-electronics; (4) geological surveying using advanced electronics and software; (5) biotechnology development; (6) aerospace engineering; (7) advanced computing and (8) research with controlled chemicals, biological agents, and toxins. Please contact KUIC for additional information/clarification.
Fundamental research exclusion applies when results are widely published and accessible. But does not apply to physical goods, material or software, or if sponsor restricts participation of foreign nationals, publication or disclosure of results; or when physical export of controlled goods or technology is expected. For more information see:
Sharing of export controlled materials, equipment, software, items and information with foreign national or countries, may require U.S. government authorization such as a license. The KU Office of Export Compliance ()can help. / Yes☐ No☐
Yes☐ No☐
Part III: Percent Contribution Allocation
Name of the Material(s): Click here to enter text.
List ALLinventors(non-KU inventors should also be included) and the percentage of their contribution below:
List percentage of contribution at the time of this disclosure. The “Contribution %” should reflect each inventor’s contribution to the Material and be agreed upon by all inventors. KUIC understands that contributions may fluctuate as the technology is developed.
If the contributors cannot agree to contribution percentages, KUIC will assume an equal distribution.
Inventors / % / List the Contributor’s Institutiononly if they were a Non-KU Employee during the research leading to this invention
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Who will be the primary contact between the KUIC and the other inventors? / Click here to enter text.
Part IV: Assignment of Rights
Name of the Material(s):

To be signed by KUinventors only.

I (we) hereby certify that all of the information set forth in this disclosure is true and compete to the best of my (our) knowledge. I (we) have also specifically reviewed and agree with the percent allocations as set forth in Part III above.

In consideration of employment by the University and receipt of a share of licensing revenues from the commercialization of inventions by the University, I (we), agree to assign and hereby do assign, sell, and transfer unto the University of Kansas, or, in the event of a prior assignment agreement, I (we) hereby confirm the prior assignment of all of my (our) right, title, and interest to this intellectual property to the University of Kansas and agree to execute any additional documents as requested to effect or support assignment to the University of Kansas of all of my (our) rights to any patent application or copyright filed on this intellectual property pursuant to the Board of Regents Policy Manual and the University of Kansas Policy on Intellectual Property.

I (we) agree to cooperate with the University of Kansas and the KU Innovation & Collaboration in the protection and commercialization of this intellectual property. The University of Kansas will share any royalty income derived from the intellectual property with the inventor(s) according to the policies of the Board of Regents and the University of Kansas and the KU Medical Center

InventorSignature and Date / Printed Name
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Signature of KUIC Representative:
______
Rajiv Kulkarni, Ph.D., MBA, CLP Date
Director, Technology Transfer, KUIC
Inventor #1
Must be filled out by each KUInventor.
Invention Title: Click here to enter text.
Name:Click here to enter text. / Position:Click here to enter text.
Citizenship/Visa Status:Click here to enter text. / KU Online ID:Click here to enter text.
Primary Phone Number:Click here to enter text. / Home Address:Click here to enter text.
KU Email:Click here to enter text. / Alternate Email:Click here to enter text.
Describe the nature of your contribution: / Click here to enter text.
If you are a faculty member, please list the department and school to which you are appointed: / Click here to enter text.
If you are not a faculty member, please list the department, center or institute in which you are employed: / Click here to enter text.
If the research leading to the invention was supported by any university-recognized centers or institutes, please list those: / 1. Click here to enter text.
2. Click here to enter text.
3. Click here to enter text.
Check the appropriate choice to describe your affiliation with Veterans Affairs (VA): / ☐No VA Appointment ☐Dually Appointed
☐Without Compensation
If you checked Without Compensation, please check the following if applicable: / Did you perform any research activities at the VA for
this invention? Yes☐ No☐
If you answered no above, were you appointed to exclusively perform clinical services, attending services, or educational activities? Yes☐ No☐
I hereby agree with the percent contribution allocation as set forth in Part III of the Invention Disclosure Form. / Signature: Date:
Inventor #2
Must be filled out by each KUInventor.
Invention Title: Click here to enter text.
Name:Click here to enter text. / Position:Click here to enter text.
Citizenship/Visa Status:Click here to enter text. / KU Online ID:Click here to enter text.
Primary Phone Number:Click here to enter text. / Home Address:Click here to enter text.
KU Email:Click here to enter text. / Alternate Email:Click here to enter text.
Describe the nature of your contribution: / Click here to enter text.
If you are a faculty member, please list the department and school to which you are appointed: / Click here to enter text.
If you are not a faculty member, please list the department, center or institute in which you are employed: / Click here to enter text.
If the research leading to the invention was supported by any university-recognized centers or institutes, please list those: / 1. Click here to enter text.
2. Click here to enter text.
3. Click here to enter text.
Check the appropriate choice to describe your affiliation with Veterans Affairs (VA): / ☐No VA Appointment ☐Dually Appointed
☐Without Compensation
If you checked Without Compensation, please check the following if applicable: / Did you perform any research activities at the VA for
this invention? Yes☐ No☐
If you answered no above, were you appointed to exclusively perform clinical services, attending services, or educational activities? Yes☐ No☐
I hereby agree with the percent contribution allocation as set forth in Part III of the Invention Disclosure Form. / Signature: Date:
Inventor #3
Must be filled out by each KUInventor.
Invention Title: Click here to enter text.
Name:Click here to enter text. / Position:Click here to enter text.
Citizenship/Visa Status:Click here to enter text. / KU Online ID:Click here to enter text.
Primary Phone Number:Click here to enter text. / Home Address:Click here to enter text.
KU Email:Click here to enter text. / Alternate Email:Click here to enter text.
Describe the nature of your contribution: / Click here to enter text.
If you are a faculty member, please list the department and school to which you are appointed: / Click here to enter text.
If you are not a faculty member, please list the department, center or institute in which you are employed: / Click here to enter text.
If the research leading to the invention was supported by any university-recognized centers or institutes, please list those: / 1. Click here to enter text.
2. Click here to enter text.
3. Click here to enter text.
Check the appropriate choice to describe your affiliation with Veterans Affairs (VA): / ☐No VA Appointment ☐Dually Appointed