CONFIDENTIAL

The Research Foundation for TheState University of New York

University at Albany

Office for Innovation Development and Commercialization

NEW TECHNOLOGY DISCLOSURE

Please submit completed form to Officefor Innovation Development and Commercialization

1. CAMPUS SUBMITTING THIS DISCLOSURE

University at Albany

2. TITLE

3. KEY WORDS

4. TYPE

 Invention  Software  Video  Other

5. PRIMARY CONTACT (among developers/inventors)

6. DATE OF CONCEPTION / /

7. SPONSORSHIP

 United States Government  Private Industry  SUNY  RF of SUNY  Personal

 Other

Name of Sponsor(s) / Research Foundation
or Campus Account Number / Sponsored Assigned
Identification Number

8. PUBLIC DISCLOSURE

a. Has the description of the technology been published?  Yes  No Date: / /

Has the description of the technology been submitted

for publication?  Yes  No Date: / /

Title of Publication

Title of Journal/Other (specify)

b. Has the technology been presented at a conference

or professional Meeting?  Yes  No Date: / /

9. BRIEF TECHNICAL CONFIDENTIAL DESCRIPTION (including its unique features) ATTACH ANY MANUSCRIPTS,

REVIEWS, PAPERS, DIAGRAMS, CHARTS, ETC.

10. PROTOTYPES AND/OR SAMPLES

a. Is a working prototype available for demonstration?  Yes  No  N/A

b. Are samples (e.g. compounds) available for testing?  Yes  No  N/A

11. ADVANTAGES OF THE TECHNOLOGY (relative to existing technology)

12. POSSIBLE DISADVANTAGES OF THE TECHNOLOGY (relative to existing technology)

13. NON-CONFIDENTIAL DESCRIPTION OF THE TECHNOLOGY

(indicate applications and advantages -- for marketing purposes)

14. LIST COMPANIES THAT YOU BELIEVE WOULD BE INTERESTED IN COMMERCIALIZING THE TECHNOLOGY

Company Name / Contact (if any) / Location/Telephone Number

15. SOFTWARE ADDENDUM : Please attach an Addendum responding to items 15.1 through 15.13. Please respond to each item, even if the answer is “None” or “Don’t know.”

  1. What does this software (“the Subject Software”) accomplish?
  2. Describe the circumstances that led to development of the Subject Software.
  3. Identify any non-software knowledge resources that were used in developing the Subject Software (e.g., subject matter experts, scientific or engineering literature resources, etc.).
  4. What, if any, pre-existing software from other sources (including any open source code) have you incorporated into the Subject Software? In each instance, describe the pre-existing software component and what function it serves, identify its source, and attach the relevant license or other permission allowing you to use the pre-existing software.
  5. Approximately what percentage of the Subject Software is new code vs. pre-existing code as identified in item 15.3 above?
  6. Give the names, affiliations, and titles of all who were involved in the design of the Subject Software.
  7. Give the names, affiliations, and titles of all who were involved in writing the code for the Subject Software.
  8. Please identify any linked content. If linked content is used, please identify and provide the license(s) for such content.
  9. To your knowledge have any copyrights been registered (or registrations been applied for) for the Subject Software or any portions of the Subject Software (including the pre-existing content identified in item 15.3 above)? If so, please give the title(s) and copyright owner(s) if you know them.
  10. Identify any grants or contracts which funded any phase of development of the Subject Software.
  11. Identify any University space, equipment, or people that were used or involved in development of the Subject Software.
  12. Has the Subject Software been described in any publication or public presentation? Has any portion of the Subject Software been published? If so, please attach the publication(s) and the date(s) of publication.
  13. Has the Subject Software, or any portion thereof, (or the right to use the Subject Software), been provided to any person or organization that is not part of SUNY or The Research Foundation of SUNY? If so, identify the recipient/user and describe how they use(d) the Subject Software.

16. SIGNED BY DEVELOPER(S) AND WITNESS(ES)

a. Name: Dr. Mr. Ms.Home Address:

Title:

Developer’s Signature: Home Telephone:

Date: Campus Address:

Country of Citizenship:

Witness’s Signature: Campus Telephone:

Date: Campus Fax Number:

b.Name: Dr. Mr. Ms.Home Address:

Title:

Developer’s Signature: Home Telephone:

Date: Campus Address:

Country of Citizenship:

Witness’s Signature: Campus Telephone:

Date: Campus Fax Number:

c.Name: Dr. Mr. Ms.Home Address:

Title:

Developer’s Signature: Home Telephone:

Date: Campus Address:

Country of Citizenship:

Witness’s Signature: Campus Telephone:

Date: Campus Fax Number:

d.Name: Dr. Mr. Ms.Home Address:

Title:

Developer’s Signature: Home Telephone:

Date: Campus Address:

Country of Citizenship:

Witness’s Signature: Campus Telephone:

Date:Campus Fax Number:

(Attach Additional Sheets If There Are More Developers)

Office for Innovation Development & Commercialization FOR OIDC USE ONLY

The Research Foundation for The

StateUniversity of New York at Albany

ES 244 Date Disclosure Received:

1400 Washington Avenue

Albany, New York12222

Telephone: (518) 442-3270 Fax: (518) 442-3350 Date of Complete Disclosure:

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