INVENTION DISCLOSURE FORM
UCSF Office of Innovation, Technology & Alliances
Case No:
Licensing Officer:
Invention Description
In this section you will provide details about your invention to help us better understand it and its commercial potential.
1. Invention Title:
2. One paragraph summary description of your invention. [If your invention has resulted from use of any Federal Government funding, please attach a detailed description (with drawings if applicable) and a manuscript, if available, as required by the Federal Government. This will help UCSF to meet its obligations to the Federal Government.][1]
3. What is the unmet need that your invention addresses?
4. What are the applications of this invention? Please identify the commercial products or services a company could develop using this technology.
5. What are the novel aspects of this invention that are improvements over existing technology?
6. What advantages will a product developed with this technology have over current technologies or products?
7. List any relevant competing technologies and products:
8. Has the invention been reduced to practice (made and tested)?
9. What are the next steps required to validate the invention both scientifically and commercially?
Potential Licensees
10. Are you aware of any companies that would be good commercialization partners for your invention? Please list.
11. Have you discussed the invention with any companies? If so, please list.
Timeline of Events
This section helps us to understand what deadlines may be associated with this invention and whether patent rights are available. Note that you should alert our office well in advance of any pending public disclosure so that we can make informed decisions regarding patent protection
12. Initial Idea
Date:
Reference and comments:
First description of complete invention, oral or written (conception)
Date:
Reference and comments:
First successful demonstrate/first actual reduction to practice
Date:
Reference and comments:
13. Has the invention been publicly disclosed? A public disclosure can include a publication, abstract, thesis, webpostings, poster presentation, oral presentation, awarded NIH grant, or conversation with persons outside of UCSF that include enough details to understand and replicate the invention.
Yes
No
14. If the invention has been disclosed, provide the exact date and source/reference of the disclosure:
15. When will the invention be publicly disclosed in the future? Provide details of the timing and type of planned disclosure.
Inventors
In this section you should list all of the contributing inventors for your invention. You should include inventors from other institutions and may add as many as you need. Under US patent law, an inventor is one who has contributed to the conception of the invention. If you are uncertain who to include as an inventor, you may review http://www.uspto.gov/web/offices/pac/mpep/documents/2100_2137_01.htm on how inventorship is determined under US patent law.
Name:
Institutional Affiliation:
Citizenship:
Position:
Dept:
Wk. Address:
Wk. Phone:
Email:
Should this person be our principal contact for this disclosure? Y/N
Name:
Institutional Affiliation:
Citizenship:
Position:
Dept:
Wk. Address:
Wk. Phone:
Email:
Should this person be our principal contact for this disclosure? Y/N
Funding Sources and Third Party Rights
In this section you will provide the information necessary for us to perform our obligations to sponsors and understand whether other organizations have rights to the invention that we need to honor.
16. In the table below, provide the full contract or grant number used for your research in development of this invention. Please include industry sponsored research, non-profit funding, governmental funding, applicable fellowships, etc., for each inventor.
Funding Source/Sponsor / Contract or Grant Number / Principal Investigator/Supervisor or Fellow to whom awarded
17. Does this invention use data or materials obtained from outside UCSF?
Yes
No
18. If yes, was the data or material obtained under either of the follow:
( ) Material Transfer Agreement - "MTA" (non-UC material) with ______
( ) A subscription to the Celera Database
Signature
Please have each inventor from UCSF sign this disclosure form before submitting it.
I HEREBY ASSIGN ALL RIGHT, TITLE, AND INTEREST, INCLUDING BUT NOT LIMITED TO COPYRIGHT AND COPYRIGHT RIGHTS, PATENT RIGHTS AND PROPERTY RIGHTS, IN THE INVENTION DISCLOSED HEREIN TO THE REGENTS OF THE UNIVERSITY OF CALIFORNIA.
Inventor's Signature:
Inventor’s Name (print):
Date:
Inventor's Signature:
Inventor’s Name (print):
Date:
Inventor's Signature:
Inventor’s Name (print):
Date:
INVENTION UNDERSTOOD BY
Witness' Signature**:
Witness’ Name (print):
Date:
Witness' Signature**:
Witness’ Name (print):
Date:
** Please have PI sign if PI is not an inventor. A suitable witness is someone who has a reasonable understanding of the invention but is not an inventor and has no vested interest in the invention.
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[1] According to the Federal Government, such description “… shall be sufficiently complete in technical detail to convey a clear understanding to the extent known at the time of the disclosure, of the nature, purpose, operation, and the physical, chemical, biological or electrical characteristics of the invention. The disclosure shall also identify any publication, on sale or public use of the invention and whether a manuscript describing the invention has been submitted for publication and, if so, whether it has been accepted for publication at the time of disclosure.”