Invention Disclosure

CONFIDENTIAL

EASTERN VIRGINIAMEDICALSCHOOL

INVENTION DISCLOSURE

• The typed original of this form should be delivered to the Office of Technology Transfer, Andrews Hall.

• This Invention Disclosure (ID) is intended to provide EVMS and the patent attorney with the information needed to determine the likelihood of obtaining a patent on the invention. This ID also will be used to prepare any patent application which may be filed on this invention. Please provide complete answers. Attach as many additional pages as necessary.

• Expeditious processing of an invention is very important. It is essential that the inventor(s) complete this report promptly in order to meet critical patent deadlines* and to facilitate an evaluation by parties interested in financing or furthering its development, patent coverage and/or commercialization.

• If unable to answer one or more of the questions at this time, indicate on the form but do not delay in submitting your disclosure for that reason.

• Questions regarding invention disclosure should be directed to the Office of Technology Transfer, 446-7112 or 446-5099.

* Important: Any patent application should be filed before any public disclosure or commercial activity in order to preserve world-wide patent rights. Any patent application must be filed in the U.S. Patent and Trademark Office within one (1) year of the first offer of sale, commercial activity, or public disclosure to preserve U.S. patent rights.

rev.10/04/12

EASTERN VIRGINIAMEDICALSCHOOL

CONFIDENTIAL DISCLOSURE FORM

Invention Title:

Submitted by EVMS Inventor:

Department: Telephone:

Mailing Address:

E-mail Address: ______

Co-Inventor(s) :

______

Name Address Telephone E-mail

______

NameAddress Telephone E-mail

(Copy and add lines for co-inventors as necessary)

I hereby certify that I will comply with the EVMS Intellectual Property/Patent Policy. I understand that my disclosure must be reviewed and accepted for patent administration according to that policy. EVMS acceptance does not imply the evaluators will find this invention patentable. I also certify that the answers herein are accurate to the best of my knowledge. If more than one inventor, the percent of interest must be indicated. The recommended interest will be used for the allocation split of any income generated by the invention unless so revised by mutual agreement of all inventor(s).

______

Signature of InventorDate

______

Signature of InventorDate

______

Signature of InventorDate

(Copy and add lines for co-inventors as necessary)

I certify I have reviewed the invention disclosure, understand the implications, including awareness of all parties involved and their assigned interest. I therefore assure that I am aware the invention is being disclosed to EVMS and that this disclosure is consistent with EVMS Patent Policy.

______

Signature of Department Chair Date

______

Signature of Department ChairDate

______

Signature of Department Chair Date

(Copy and add lines for Chair signatures as necessary)

I.Description

A.Describe what you consider to be the invention. Use additional sheets as necessary to elaborate; attach descriptive materials including reports, sketches, drawings, photographs and blueprints which may illustrate or explain the invention. If a model, prototype or film has been made, please indicate where it may be seen or obtained. Also provide pertinent experimental data.

B.How does the invention differ from present technology? What problems does it solve, or what advantages does it possess? How was this problem solved in the past, by you or others?

C.How is your solution of the problem (i.e., the invention) better than or different from the past solutions? Describe specifically any technical or economic advantage or disadvantages your invention may have over the past solutions.

D.If not indicated above, what are possible uses for the invention? In addition to immediate applications, are there other uses that might be realized in the future? Describe, if appropriate, the "best" way to make or use the invention: will the way you will practice the invention commercially be different from the best way?

E.Please describe alternative ways to practice the invention. Describe substitute materials, ranges of conditions and structural or process variations that work, even if not as well as the best way. Are the alternatives based on theory, analogy, experience or actual experimental data?

II.Limitations

Does the invention possess disadvantages or limitations?

 Yes No

If yes, how can they be overcome?

III.Origin and Development of the Invention

A.When and where was the invention first conceived? Describe any documents which confirm this event. When was the first successful test of the invention? Describe any document which confirms this event.

B.Has the invention been used in a commercial environment or for a commercial test? If so, where and when? List each such occurrence starting from the earliest date and describe the circumstances

C.Has the invention in some form been sold or offered for sale, for example, incorporated in equipment or in a composition or included in a project proposal or bid? If so, list each sale or offer, giving the details and date of each.

D.Have plans been made to commercialize, use, sell, offer to sell, or disclose the invention outside the institution? If so, to whom and when.

E.Were materials or data owned by an entity other than EVMS or the institution of co-inventors used in the research/activities that led to this invention? If yes, was a material transfer agreement or data transfer agreement executed? If an agreement was executed, attach a copy to this disclosure.

IV.Research and Development Costs

A.If further research and development is necessary or desirable prior to patent filing or presenting the invention to a potential licensee, please discuss, indicating, the estimated cost and length of time, if possible.

V.Publications Prior Disclosure

A.List all prior publications pertaining to the invention. Include theses, reports, preprints, reprints, manuscripts for publication (submitted or not), news releases, feature articles or items for internal publications. Please include publication dates and provide copies whenever possible.

B.Has the invention been shown or described to persons not employed by the EasternVirginiaMedicalSchool in a technical meeting, presentation, talk, trade show or similar event? If so, describe the persons, dates, and circumstances of the disclosure.

C.If public disclosure or publication is planned in next twelve months, indicate date, place and circumstance(s). Attach a copy of any proposed disclosure.

1. Has the invention been used in patient care? If so, how and when.

VI.Scientific Data

A.If laboratory records and data are available, please provide reference numbers and physical location, but do not enclose.

VII.Known Patents or Publications

A.List any like/similar patents or publication(s) of which you are aware.

VIII.Sponsor Information

If the work that led to the invention was sponsored, please provide the following information:

Name of Sponsor:______

Grant or Contract Identification (if any):______

Title of Project: ______

______

Principal investigator:______

IX.Commercial or Market Interest

A.Indicate and commercial or market interest in the invention at this time. Provide company names, in addition to the titles of persons interested.

B.Suggest any other firms which might be interested in the invention.

X.Conception

1. In the opinion of the inventor(s), was the invention conceived, actually reduced to practice, constructively reduced to practice or development during a time when the inventor was an employee or student of the EVMS/MCHR?

 Yes No

1. If yes, did the invention result from a specifically assigned project?

 Yes No

C.Was the invention conceived, reduced to practice or development: (1) during working hours, or (2) within the scope of the inventor's employment, or (3) when using EVMS/MCHR or EVMS/MCHR-controlled facilities?

 Yes No

XI.Percent Interest

A.Indicate percent interestof ALL of the Inventor(s) as mutually agreed for submission of this disclosure.The percent interest should sum to 100%.

All Inventor(s)% Interest

Name ______

Signature ______Date ______

Name ______

Signature ______Date ______

Name ______

Signature ______Date ______

(Copy and add lines for co-inventors as necessary)

B.The EVMS Patent Policy provides that inventors collectively receive one-third of net revenue realized by EVMS from the invention. Indicate percent division of EVMS inventors’ share of net revenue as mutually agreed for submission of this disclosure. The percent division of the EVMS inventors’ share should sum to 100%.

For non-EVMS inventors from other institutions and/or entities, EVMS will enter into an agreement that provides for the sharing of gross revenue between EVMS and thoseentities, and subsequent revenue will be distributed according to the policies of their institutions and/or entities.

EVMS Inventor(s)% Division

Name ______

Signature ______Date ______

Name ______

Signature ______Date ______

Name ______

Signature ______Date ______

(Copy and add lines for co-inventors as necessary)

XII.External Financial Interests of Inventors (to be completed by each inventor)

(Copy and add section for each co-inventor)

Inventor : Name______

Have you filed a financial disclosure form with the EVMS Office of Research in the last 12 months?

 Yes No

If the answer to the above question is no, please answer the following questions.

Are you or any member of your household employed (or receive compensation) by(from) an entity other than EVMS?

 Yes No

If yes, please attach a list of these employments, or sources of compensation. List by member of the household.

Do you or any member of your household have an ownership interest (including stock and stock options) in business entities? This does not include holdings through mutual funds.

 Yes No

If yes, please attach a list of these ownership interests. List by member of the household.

rev.10/04/12