Utmb Invention Disclosure Form

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CONFIDENTIAL

UTMB INVENTION DISCLOSURE FORM

If you plan to publish, present, or disclose within 30 days, please check here:

PART 1: INVENTORS

Who is an inventor? An inventor is a person who contributed to the conception of at least one patent claim. Since we do not yet know the claims, please identify each person who helped conceive of at least one new feature of the invention. A final determination of inventorship will be made according to US patent law.

* Please indicate how licensing revenue received from the commercialization of this invention should be distributed among the contributors. Under IHOP policy 1.1.4, licensing revenue will be divided as follows (after recapture of patent costs): 50% to inventor(s), 25% to the inventor(s) laboratory or facility, 25% to the President's Royalty Fund to support research at UTMB. See http://www.utmb.edu/TechTransfer/resources/

PART 2: INVENTION

Please describe the technical aspects of your invention. What problem does it solve? How is it different from existing alternative solutions?

See attachments containing additional description, data, and figures

(Number of attachments:)

PART 3: FUNDING AND SUPPORT

1. Was the invention supported by funds from an outside source? Yes No

(e.g., Federal government, Foundation, Company, or Private Gift) If yes, please identify each source:

2. Does the invention use any Biological Material from an outside source? Yes No

If yes, please identify the source, and attach Material Transfer documentation.

3. This invention was developed using (check all that apply):

UTMB facilities (including laboratories, clinics)

UTMB equipment (including computers)

UTMB resources (including employees)

Part 4: Disclosure

"Disclosure" includes: publications (online or in print), presentations (oral or written), posters, abstracts, demonstrations, offers for sale, sales, etc. In short, a disclosure is a communication to anyone who does not owe a duty of confidentiality.

Please select one of the following options:

The invention has NOT YET been disclosed.

We plan publish/present the invention on this date:

The invention has already been disclosed.

The invention was published/presented on:

Thank you for participating in UTMB's Technology Transfer process by completing this Invention Disclosure Form. We will contact you to confirm the receipt date of your completed form and the assigned technology identification number for your reference.

Our goal is to decide whether or not to file a patent application within 90 days of receiving your completed form. Our decision will be based on an analysis of the patentability and marketability of your invention. To assist us in this analysis, you are invited, but not required, to provide information about these factors:

Part 5: Prior Art (Patentability) (optional)

You are not required to search scientific or patent literature. However, if you are aware of any references that are relevant to the new features of your invention, please provide them here: (If the references are your own work, they should be listed above in Part 4.)

part 6: commercial opportunities (Marketability) (optional)

Are you aware of companies that may be interested in licensing your technology? Please describe them here:

How did you hear about us? Please select the statement that most closely describes how you decided to disclose this invention:

I have disclosed inventions to the Office of Technology Transfer (OTT) before.

I learned about the invention disclosure process from an OTT staff member.

I learned about the invention disclosure process on the OTT webpage.

A colleague suggested I contact the OTT. Name: