Intellectual Property Questionnaire - Copyright

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Intellectual Property Questionnaire (IPQ)
for Copyrightable Works

The attached form has been designed as a download; please feel free to expand the spaces provided so that you may answer questions completely and to duplicate blocks for adding additional contributors, research sponsors, and publications.

Please include with this submission:

A copy of the copyrightable work

Official processing of this invention disclosure cannot begin until it is fully completed, signed by all UT inventors and the principal investigator for the research (whether or not the principal investigator is an inventor), and submitted to the Office of Technology Commercialization.

1.Title suggested by creators:______

2.Please list all those who contributed to the creation of the work. (Copy this block to list additional contributors.)

Name______EID______

Department______Position______

Work address______Work phone______

Email______Fax______

Home address______Home phone______

Country of citizenship______Other appt______

Contributor's signature______

Name______EID______

Department______Position______

Work address______Work phone______

Email______Fax______

Home address______Home phone______

Country of citizenship______Other appt______

Contributor's signature______

Name______EID______

Department______Position______

Work address______Work phone______

Email______Fax______

Home address______Home phone______

Country of citizenship______Other appt______

Contributor's signature______

3.Wereallcreators acting in their capacity as employees of The University of Texas at Austin during the development of this work?
(check one) []Yes[]No

If No, please identify and explain:______

4.Please check all that apply:

[] (a) The work was created by an employee, student or other individual commissioned,
required or hired specifically to produce such work by UT.

[](b) The work was created by an employee or student as part of an institutional project.

[](c) Clauses (a) and (b) above do not apply to the creators, and the work is
a scholarly or educational material, artwork, musical composition or
literary work related to the creator’s academic or professional field.

[](d) Other (please explain):______

5.Please provide a brief description of the work, including the purpose of the work and its intended users.

6.What is the form of the copyrightable work (e.g., text, manual, motion picture, screenplay, etc.)?

7.Do you anticipate producing the work in any other form (e.g., web-based, video, audio, screenplay, etc.)?(check one) []Yes[]No

8.Provide the dates (month and year) that development of the work began and that development was completed. (Indicate if approximate.)

Date begun:______

Date completed:______

9.Please list the date (day/month/year) of publication, if applicable:______

10.Are materials that are owned and/or authored by persons or entities other than those listed in Question 2 incorporated into the work?(check one) []Yes[]No

If Yes, please list all third-party sources:

Has the author of those materials given authorization to incorporate them into this work?
(check one) []Yes[]No

If Yes, please attach the documentation giving authorization or state the source of the authorization.

11.Is the work a derivative work?(check one) []Yes[]No

If Yes, name the work from which it was derived:______

Has the author of this work given authorization to create derivative works?
(check one) []Yes[]No

If Yes, please attach the documentation giving authorization or state the source of the authorization.

12.What companies do you believe would be interested in licensing or distributing the work?

13.Have you been approached by any companies regarding the work? (check one) []Yes[]No

If Yes, which companies? (List contact names if available.)

14.Was the development of thiswork supported by a grant or contract?
(check one) []Yes[]No

If Yes, please list below. If No, please explain why you believe this work is outside any
existing sponsored research:______

Note:Types of sponsors include but are not limited to, NIH, other federal agencies, state agencies, non-profit research foundations, and private companies. Gift contributions need not be listed. (Copy this block to list additional sponsors.)

Name of sponsor:______

Title of project:______

UT Austin acct #:______

Grant #:______

Name of sponsor:______

Title of project:______

UT Austin acct #:______

Grant #:______

Name of sponsor:______

Title of project:______

UT Austin acct #:______

Grant #:______

15.Do you have any other current sponsored research agreements in place?
(check one) []Yes[]No

If Yes, please list below. If No, please explain why you believe this research result is outside any
existing sponsored research:______

Name of sponsor:______

Title of project:______

UT Austin acct #:______

Grant #:______

Name of sponsor:______

Title of project:______

UT Austin acct #:______

Grant #:______

16.Non-Proprietary Description – This one-page form will be used to market your copyrightable work through OTC's web site and for mailing preliminary information to interested parties, including the media. The text should be understandable by anyone who is semi-skilled in your subject area. Examples can be found at:

UTA # ______(S)

Office Use

Non-Proprietary Description

Please send an electronic version of this Non-Proprietary Description .

Title:

Background:

(Why is there a need for such a work? What are the drawbacks of other, similar works if available?)

Invention Description:

(A non-proprietary description of the work)

Features:

(The characteristics of the work: coded in assembly/binds selectively to XYZ receptor/etc.)

Benefits:

(The results of the features. Why do I care? 2X faster operation/fewer side effects/cheap to produce/etc.)

Markets:

(Who might be interested in your work? Quantify if possible; cite sources)

Development Stage:

(Choose one:
Idea / Proof of concept / Draft / In revision or editing / Published)