CASE NO.
Brought in by:

PROPRIETARY INFORMATION

UC SAN DIEGO

OFFICE OF INNOVATION AND COMMERCIALIZATION

COPYRIGHT DISCLOSURE FORM

Please use additional sheets as necessary.

1. Title of work:

2.Description of work: (If software is part of this disclosure, please also complete Appendix A, and check here: SOFTWARE)

3. Name(s) of Author(s):

UCSD AUTHOR(S):

Name: / UCSD Employee #:
Citizenship: / Position:
School or Division:
Dept. or ORU: / Work Address:
UCSD Mail Code:
Work. Phone: / Work. Fax: / Email:
Home Address: / Home Phone:
Home Email:
Name: / UCSD Employee #:
Citizenship: / Position:
School or Division:
Dept. or ORU: / Work Address:
UCSD Mail Code:
Work. Phone: / Work. Fax: / Email:
Home Address: / Home Phone:
Home Email:
Name: / UCSD Employee #:
Citizenship: / Position:
School or Division:
Dept. or ORU: / Work Address:
UCSD Mail Code:
Work. Phone: / Work. Fax: / Email:
Home Address: / Home Phone:
Home Email:

UCSD AUTHORS (Cont’d)

Name: / UCSD Employee #:
Citizenship: / Position:
School or Division:
Dept. or ORU: / Work Address:
UCSD Mail Code:
Work. Phone: / Work. Fax: / Email:
Home Address: / Home Phone:
Home Email:
Name: / UCSD Employee #:
Citizenship: / Position:
School or Division:
Dept. or ORU: / Work Address:
UCSD Mail Code:
Work. Phone: / Work. Fax: / Email:
Home Address: / Home Phone:
Home Email:

NON-UCSD AUTHOR(S):

Name: / Position: / Nature of Employment:
Employer: / Work Address:
Work. Phone: / Work. Fax: / Email:
Name: / Position: / Nature of Employment:
Employer: / Work Address:
Work. Phone: / Work. Fax: / Email:

4.Funding/Sponsor (include intramural and extramural funds with relevant award numbers):

5.Completion date of award project: ______

6.Has this work been distributed within or outside of the University? Yes No

If yes, please describe to whom and the circumstances below:

7.Does the work display a copyright notice?  Yes  No

If yes, reproduce it here:

8.If the work incorporates the efforts of others, please describe how and include others’ name and address.

  1. List any companies that may be interested in development and distribution of this work.

10.I have received a copy of the UC Copyright Policy and the implementation guidelines and agree to abide by the terms therein.

Signature of all authors:

______

Author signatureDate

______

Author signatureDate

______

Author signatureDate

______

Author signatureDate

______

Author signatureDate

If you would like help in completing this form, please call our main number at (858) 534-5815. You may fax the completed copyright form to ouroffice at (858) 534-7345, with the original document submitted to:

Office of Innovation and Commercialization

University of California, San Diego

9500 Gilman Drive MC 0910

La Jolla, CA 92093-0910

Tel: 858-534-5815

Fax: 858-534-7345

…pipeline to innovation

UNIVERSITY OF CALIFORNIA, SAN DIEGO

COPYRIGHT DISCLOSURE FORM

APPENDIX A (For Software)

  1. RECOMMENDED HARDWARE REQUIREMENTS:

Computer Manufacturer.Model:
Internal Memory Requirements:
Input/Output Devices:
Other Peripherals:
  1. RECOMMENDED OPERATING SYSTEM REQUIREMENTS:

Operating System, Version No.
Compiler:
Other Software Required:
  1. DOCUMENTATION (For each item identify type of document: [A] HARD COPY; [B] ON-LINE; [C] BOTH; [D] NONE)

User’s Guide / Control Information / Sample Problem Input
Installation Guide / Data Libraries / Sample Problem Output
Technical Documentation / Illustrations

4. MEDIA:

Media Type:

Media contains: Source Code Object Code

  1. COPYRIGHT QUESTIONS:

Please answer Yes or No to the following questions. If any answers are yes, attach an additional sheet with explanations.

Was any of the code written by someone who is not listed as a author (e.g., student performing under direction of faculty)?
Was any of the code used subject to a prior copyright or patent?
Has the softeware been discussed and/or any of the code published in a thesis or article?
Does the software include creator acknowledgment?
Does the software include a copyright notice?
Does the software include a sponsorship acknowledgment?
  1. MARKETING QUESTIONS:

Describe the audience for whom the item was designed:

Are there similar items currently in the marketplace?