Invention Disclosure_Temple OTCBD

Technology Commercialization and Business Development

research.temple.edu/innovation

Phone 215-204-5732 |Fax 215-204-7486


CONFIDENTIAL INVENTION DISCLOSURE


Instructions

  • Please forward the forms alongwith the supplementary documentation either electronically or by mail. The Declaration page must be duly signed and sent in ORIGINAL to our office at:

Office of Technology Commercialization & Business Development

1801 N. Broad St., Suite401

Philadelphia, PA 19122-6027

(P) 215 204 5732

(F) 215 204 7486


Copyright © 2016Office of TechnologyCommercialization and Business Development, Temple University - Of the Commonwealth System of Higher Education. All Rights Reserved. Nothing contained in this report may be used or copied without the express written permission of TempleUniversity.

Technology Commercialization and Business Development
research.temple.edu/innovation
Phone 215 204 5732 Fax 215 204 7486
Please email completed disclosure form to
CONFIDENTIAL INVENTION DISCLOSURE
For OTCBD Use Only a) OTCBD Ref. No.: b) Date Received:
1. Title of the invention:
2. Is this invention related to a previous invention disclosed to OTCBD? / Yes No
3. List relevant KEYWORS
related to your invention,
discovery or new technology:
4. Identify the sources of funding below: (Federal, State, Institutional, Industry, Foundational Funding or other)including funding for salaries, materials and equipment for inventors. Please list all grants which provided support thathelped to defray costs during the research. Federal law requires the Temple University to report all new technologies supported by federal funding to the Government. / 5. Date of conception of invention:
1) / Agency / Grant No.
2) / Agency / Grant No.
3) / Agency / Grant No.
6. Contributors: The “Royalty %” should reflect each inventor’s contribution to the concepts of the invention and be agreed upon by all inventors. If the inventors cannot agree to contribution percentages, OTCBD will assume an equal distribution.
No. / TitleMr./Ms./Dr. / Name (First-MI-Last) / Position / Department / % Royalty*
i)
ii)
iii)
iv)
7. Primary Contact:This individual agrees to keep the other inventors and/or contributors informed, on a timely basis, of all developments related to the invention as communicated by OTCBD and the outside patent counsel.
Name / Email / Phone
*% Royalty – Denotes the share each individual shall receive upon the commercialization of the invention.

Each CONTRIBUTOR must complete this form:

First Name / Middle Initial / Last Name
Work Address: / Home Address:
City, State, Zip, Country: / City, State, Zip, Country:
Phone: / Phone:
Fax: / Fax:
E-mail: / Personal E-mail:
Citizenship:

Declaration

I have read, understood, and agreed to be bound by the current Temple University Invention and Patent Policy.

Pursuant to GUIDELINE #12 of the Invention and Patent Policy: Net income distribution toinventors who cannot be located, after reasonable attempts have been made to locate them, will revert to the University three years from the date the first attempt was made. Reasonable attempts may include, where appropriate: inquiries with thesis advisor, searches of Graduate School and Alumni records, searches of professional literature, inquiries with professional societies, web searches.

Please notify OTCBDin writing of any change in your correspondence address as promptly as possible:

Stephen G Nappi, Associate Vice President

Technology Commercialization

and Business Development

Temple University

1801 North Broad Street, Suite 401

Philadelphia, PA 19122-6027

______

(Signature)

(Printed Name)(Date)

QUESTIONNAIRE

(10 key questions)

  1. Abstract or Brief Description of the invention.

  1. Detailed Description of the invention. Attach a manuscript if available.Describe your plans for additional research in the area of the invention. Use additional sheets as necessary. (Experimental Data, Results and Discussion)

  1. List the current state(s) of the technology and draw a comparison chart with respect to your invention. Describe the novelty and major advantages of your invention over existing alternatives, including responses to the following questions: Howwill your innovation or discoveryaddress a problem that exists in the industry today; what are the existing products/services/methods that are available to address the problem; what are the issues with the other products/solutions; and what are the limitations of your invention?

  1. Foreseeable applications of the invention. (E.g.: What would be the end product for your invention?) Use a bullet point listing.

  1. Public disclosure of your invention (Oral presentations, posters, publications). Have you made it or used it (if yes, on what date?). Please indicate scheduled public disclosures which may be in the form of a publication or presentation.

  1. Use of materials, software code, or licensed technologies obtained from external sources. In addition, please indicate materials used from other institutions (Did you create this invention using materials from another institution) and name those institutions.

  1. List the names of other academic groups and/or companies working in this area.

  1. List the names of companies that might be interested in licensing the invention.

  1. Please indicate completion of a model or prototype along with date of first successful operational test.
  1. If your invention is a software, please describe the language(s) used, the stage of development your software is in (concept, beta, research tool, read to license, prototype, etc.), the platforms on which your software runs (if applicable is it portable to other platforms? Is there any required software or hardware needed in order to run your software?), and whether any open-source or third party code is embedded (including where its sourced from, how it is utilized, and any licenses that may be involved).

Additional Information.
Please attach manuscripts, relevant publications, patents, drawings and user manuals. Hand drawings are acceptable provided important details are demonstrated. Please attach separate drawing sheets with this form. Please number the drawings and highlight specific parts/elements within the drawings (if necessary). Also, please provide one sentence describing each drawing

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v. 6/10/161