Form 900

V20170516

1 of 4

TECHNOLOGY TRANSFER & COMMERCIALIZATION (T2C) OFFICE

INVENTION DISCLOSURE FORM 900

INFORMATION WILL BE KEPT CONFIDENTIAL

QUESTIONS?

Please call 240-694-4028or send an email to HJFif you have questions and/or need assistance in completing this form.

I.Title of Project/Invention:

II. Date of next planned disclosure:

III.Keywords:Please provide 4-6 keywords that are related to this invention.

IV.Name of the Contact Person for this Invention Disclosure.

Last Name: / First Name:

The Contact Person is knowledgeable about the entire scope of the disclosure and will be responsible for:

1. Communicating with other researchers involved in project, T2C, HJF, patent counsel; and

2. Providing documents and information requested by T2C and/or patent counsel; and

3. Notifying T2C of any updates and additional data to be considered; and

4. Notification to Department Head of Invention Disclosure.

  1. Individual(s) Who Contributed Conceptually to the Invention. If there is more than one inventor, please use Attachment B. Additionally, please have each inventor fill out a separate Research Contribution Page (found at the end of this document).

Legal name: / Citizenship:
Work Phone: / Home Phone:
Email Address: / Alternate email address:
Work Address: / Home Address:
Employer: / Department:
Degree(s): / Rank (if military):
Percentage contribution to Invention:

VI.Invention Description

  1. Brief summary of the invention: Please provide 2-3 sentences on what the invention is/does.
  1. Detailed description of the invention:

(a) What is the need? What potential product, process, or service could develop from invention?

(b) How does it work? Describe how your invention functions, including details so that anyone with your level of skill could make/carry out the invention. Attach drawings, sketches, photographs, flow charts, etc., to illustrate the invention and/or its components.

(c) Competition?What are the potential alternatives to the invention and what advantages and/or disadvantages does the invention have compared these alternatives?

(d) New features? Are there components of the invention that are believed to be new?

(e) Other details?

  1. Invention conception:

(a) When did you first conceive of this idea and where is the conceptdocumented (lab notebooks, proposal, correspondence, computer files, etc.)?

(b) Have you previously disclosed this or a related invention to T2C?

  1. Stage of development: What stage of development is the invention (i.e. concept/initial data/prototype/complete data/In vitro data/animal data/clinical data) and what additional developments are expected?
VII.Third Party Interests: In developing this invention, were any compounds, biological materials or devices obtained from sources outside your lab? If so, please provide details.
VIII.Related Agreements:Is any research in this disclosure subject to a Cooperative Research and Development Agreement (CRADA), Material Transfer Agreement (MTA), Subaward, Contract or other collaborative agreement? If so, please provide details.
IX.Funding Source(s): What funding source(s) was used to develop the invention, (i.e. salary, reagents etc.)?
Please enter detailed information in the table below as appropriate:
Funding Agency
(i.e. NIH) / Grant/Award/Contract #
(i.e. CA182383) / Principal Investigator*
(i.e. William Smith)
  1. Disclosures: Please check appropriate boxes and completethe charts below as applicable as public disclosures can affect patent rights.

Type of Past and/or Submitted Disclosure / Yes / No / Date of disclosure & citation/reference
Have you published an abstract or manuscript about the inventions (please include advance online postings)?
Presented at a meeting or conference?
Disclosed as part of an awarded grant or a thesis?
Written or oral disclosure of invention with a third party NOTunder a non-disclosure agreement (NDA)?
Written or oral disclosure of invention with a third party while under a non-disclosure agreement (NDA)?
Other past disclosure(s)?
Type of Future Disclosure / Yes / No / Planned date of disclosureexplanation (i.e. NIH grant submission)
Have you submitted an article for publication?
Do you plan to submit a grant for review?
Do you plan to present at an upcoming meeting?
Other upcoming disclosure(s)?

XI.Commercialization

  1. List possible commercial applications (i.e. products) that you think could be of interest to companies.
  1. If applicable, please list any competitive products, patents and/or publications in the field that are related to this invention.

XII.Potential Company Partners: Identify companies you think might be interested in this invention.

If applicable, please include current contact information of any company personnel you have been speaking to:

Company / Contact Name, Telephone, Email / Prior Meeting Date / Planned Meeting Date

XIII.Signatures:

Signature of Inventor (i.e. person completing this form):

Signature: / Date:
Name: / Phone:

Signature of Witness (Individual that is aware of and understands the invention)

Signature: / Date:
Name: / Phone:

XIV.Submission: Upon completion of this form, please e-mail to or mail to HJF T2C, 6720A Rockledge Drive, Suite 100, Bethesda, Maryland 20817. The T2C office will contact you within 72 hours business hours of receipt and to set-up a time for discussion.

Thank you!

Confidential and Proprietary

Form 900

V20170516

ATTACHMENT A

RESEARCH CONTRIBUTION PAGE

(PLEASE USE SEPARATE PAGE FOR EACH CONTRIBUTOR)

QUESTIONS? Please call 240-694-4028or send an email to HJF

Individual Who Participated in the Research Related to This Disclosure:

Name: / Citizenship:
Work Phone: / Home Phone:
Email Address: / Alternate email address:
Work Address: / Home Address:
Employer: / Department:
Degree(s): / Rank (if military):
Percentage Contribution to Invention:
Title of Project:

Please provide a description of your contribution below. We have providedthe following question prompts as a guide:

  • What was your contribution to the concept of the invention?
  • Was the idea originally generated in a group discussion? If so, who was in the group and what did they contribute?
  • To what aspects of the invention did you contribute? Which aspects were your original ideas? (i.e., were you the first person to mentally imagine this aspect?)
  • Were you involved in carrying out the experiments to make the invention work? If yes, did you generate new ideas and/or improvements during these experiments?

Submission: Upon completion of this form, please e-mail to or mail to HJF T2C, 6720A Rockledge Drive, Suite 100, Bethesda, Maryland 20817. The T2C office will contact you to confirm receipt and set up a time for discussion.

Thank you!

ATTACHMENT B

Name: / Citizenship:
Work Phone: / Home Phone:
Email Address: / Alternate email address:
Work Address: / Home Address:
Employer: / Department:
Degree(s) / Rank (if military)
Percentage Contribution to Invention:
Name: / Citizenship:
Work Phone: / Home Phone:
Email Address: / Alternate email address:
Work Address: / Home Address:
Employer: / Department:
Degree(s) / Rank (if military)
Percentage Contribution to Invention:
Name: / Citizenship:
Work Phone: / Home Phone:
Email Address: / Alternate email address:
Work Address: / Home Address:
Employer: / Department:
Degree(s) / Rank (if military)
Percentage Contribution to Invention:
Name: / Citizenship:
Work Phone: / Home Phone:
Email Address: / Alternate email address:
Work Address: / Home Address:
Employer: / Department:
Degree(s) / Rank (if military)
Percentage Contribution to Invention:
Name: / Citizenship:
Work Phone: / Home Phone:
Email Address: / Alternate email address:
Work Address: / Home Address:
Employer: / Department:
Degree(s) / Rank (if military)
Percentage Contribution to Invention:

OFFICE USE ONLY

Date rec’d by T2C ___

HJF#______