Disclosure of Copyrightable WorkConfidential
MUSC
Page 1
DISCLOSURE OF COPYRIGHTABLE WORK
Medical University of South Carolina
Author(s)
Name:
Title:
MUSC Address:
Department:
Work Telephone:
Home Address:
Home Telephone:
Citizenship:
Title of Copyrightable Work
Brief Description
Publication
a. Has work relating to the copyrightable work been published or submitted for publication? Yes No
If YES, complete the following:
Date Submitted:
Date Published:
Reference (attach reprint)
Did the published material carry a copyright notice? Yes No
b. Has the work been presented? Yes No
If YES, complete the following
Date of abstract submission if any:
Date of abstract publication (attach copy):
Date of presentation:
Place of presentation:
Did the published material carry a copyright notice? Yes No
c. Has a copyright been filed describing the work? Yes No
If YES, attach a copy of the form
d. Has the work been otherwise publicly presented? Yes No
If YES, give date and circumstances:
e. Has the material been made available to any company? Yes No
If YES, complete the following:
Date:
To Whom:
Address:
Support
a. Was the University’s time used in work relating to the copyrightable material? Yes No
If YES, briefly describe:
b. Did any other University staff contribute to the production of copyrightable work? Yes No
If YES, name contributor(s) and briefly describe their contribution:
c. Were University facilities used in producing the copyrightable work? Yes No
If YES, briefly describe:
d. Was any activity relating to production of the copyrightable work supported by non-University funds?
Yes No
If YES, answer the following:
Was it sponsored by federal funds? Yes No
Name of Sponsoring Agency:
Grant or Contract Number:
e. Was any activity sponsored by private funds? Yes No
If YES, was there an agreement with a private sponsor? Yes No
If YES, list name of Sponsor:
COMMERCIAL INTEREST
a. Has any company shown an interest in the copyrightable work? Yes No
If YES, give company name and person contacted:
Company Name:
Contact Person:
b. Do you know of any companies that may be interested? If so, please list:
AUTHOR(S) RECOMMENDATIONS
What plans do you have for the use of the copyrightable work?
AUTHOR(S) SIGNATURES
Name:Name:Name:
Date:Date:Date:
Witness:Witness:Witness
SUPERVISOR’S ENDORSEMENT (This section will normally be completed by the Department Chair.)
I have reviewed the information provided above with particular reference to items 5 and 7. To the best of my knowledge, I believe the above statements to be accurate:
Signature:Date:
Name Typed
Received by Intellectual Property Committee Chair (Date)
Disclosure of Copyrightable WorkConfidential
MUSC
Page 1