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University of VirginiaResearch Reagent

Disclosure Form

/ Submit completed forms to:
U.Va.Licensing & Ventures Group
250 W. Main St., Suite 300
Charlottesville, VA 22902
(434) 924-2175 |
The purpose of this form is to facilitate the prompt disclosure by University of Virginia (U.Va.) faculty and staff of any laboratory research reagents (e.g., monoclonal and polyclonal antibodies, immortalized cell lines, mouse strains, etc.) that result from University research pursuant to the U.Va. Patent Policy effective June 23, 1993.Please review the attached instructions and guidelines.
Please note: This form is to be used for laboratory research reagents only. If your reagent may have broader applications (e.g., as a diagnostic or therapeutic, etc.), please instead complete the Intellectual Property Disclosure Form available at
1. Title of Research Reagent
Click here to enter text. / 3. Inventors*
U.Va. ContributorLegal Name / Primary Department at U.Va. / % Contribution
(Column must total 100)
2. Description:Pleaseprovide a brief summary of the reagent and its uses, referring to the instructions on Page 4.
Click here to enter text. / Department / % /
Department / % /
Department / % /
Department / % /
Department / % /
Non-U.Va. ContributorLegal Name / Employer/Institution / % Contribution
Institution / % /
Institution / % /
Institution / % /
Institution / % /
*Please list all persons who are believed to have made significant contributions to the generation of the research reagent, including U.Va. faculty and staff as well as inventors from other institutions, in the appropriate fields above.
4. Was this intellectual property developed with the use of any research grant/contract funds?< Click to select YES or NO >
Grant/Contract No.SponsorPrincipal Investigator
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5. Please list any material transfer agreements (incoming and/or outgoing) or other agreements (confidentiality agreements, etc. — other than those listed in Section 4 above) that are relevant to this research reagent.
Institution/CompanyDateMaterial
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6. Publications: Please include reference and URL if available.
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7. Please list any potential licensees or commercial partners.
Please provide as much detail as possible, including any professional contacts and contact information.
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8. Type of Research Reagent: < SELECT REAGENT TYPE >
If monoclonal antibody, skip to Section 9.
If polyclonal antibody, skip to Section 10.
If mouse strain, skip to Section 11.
If other (plasmids, recombinant proteins, cell lines, etc.), skip to Section 12.
9. For Monoclonal Antibodies Only
A. Immunogen Information
  1. Protein name(s):Enter text.
  2. Species:Enter text.
  3. Accession number and database (if known):Enter text.
  4. Type of immunogen: < SELECT >
    If “Other,” describe type:Enter text.
  5. Is the immunogen full length or partial?
    < SELECT >
    If “Partial,” specify amino acids:Enter text.
  6. The immunogen is:< SELECT >
    If “Mutant/post-translationally modified,”describe:Enter text.
  7. Fusion partner (e.g., FLAG, KLH, GST, 6-His, etc.):Enter text.
/ B. Hybridoma Information
  1. Species immunized (lymphoid cells derived from): Enter text.
  2. Myeloma parent: Enter text.
  3. Clone number: Enter text.
  4. Produced as …
    Acites?: < SELECT >
    Culture supernatant?: < SELECT >
  5. Immunoglobulin isotype: Enter text.
  6. Antibody purification method: Enter text.
/ D. The Lymphocyte Culture Center
The U.Va. Licensing & Ventures Group (LVG) maintains a permanent collection of monoclonal antibody hybridomas at the U.Va. Lymphocyte Culture Center (LCC). If your material is not on deposit there, please make the deposit with instructions to the LCC indicating that the material is for the U.Va. LVG collection. Depositing your material into this collection will allow LVG to distribute your hybridoma after licensing, relieving your lab of the burden of packaging and shipping responsibilities. Our collection will also serve as a back-up source of your hybridoma. This service applies to monoclonal antibodies only. You will not be billed for this service.
If already deposited, date of deposit: MM/DD/YYYY
C. Antigen Information
  1. Epitope (if known): Enter text.
  2. Species cross-reactivity: Enter text.
  3. Enter concentrations for any tested applications:
    WB: Enter text.
    ELISA: Enter text.
    IF(ICC): Enter text.
    IHC: Enter text.
    IP: Enter text.
    Other (specify application and concentration): Enter text.

10. For Polyclonal Antibodies Only / 11. For Mouse Strains Only
  1. Protein name(s):Enter text.
  2. Species:Enter text.
  3. Accession number (specify database, if known):Enter text.
  4. Type of immunogen: < SELECT >
    If “Other,” describe type:Enter text.
  5. Is the immunogen full length or partial? < SELECT >
    If “Partial,” specify amino acids:Enter text.
  6. The immunogen is:< SELECT >
    If “Mutant/post-translationally modified,describe: Enter text.
  7. Fusion partner (e.g., FLAG, KLH, GST, 6-His, etc.):Enter text.
  8. Antibody information
  1. Species immunized:Enter text.
  2. Immunoglobulin isotype: Enter text.
  3. Epitope (if known):Enter text.
  4. Species cross-reactivity:Enter text.
  5. Enter concentrations for any tested applications:
    WB: Enter text.
    ELISA: Enter text.
    IF(ICC): Enter text.
    IHC: Enter text.
    IP: Enter text.
    Other (specify application and concentration): Enter text.
  6. Type of material available: < SELECT >
    If “Purified antibody,” describe purification method: Enter text.
  7. Amount available (ml):Enter text.
/
  1. For Targeted Mutation Strain Generation Only
  1. Founder background:Enter text.
  2. Donor background:Enter text.
  3. Targeted gene name:Enter text.
  4. Strain nomenclature (if known, as described by the International Committee on Standardized Genetic Nomenclature for Mice):Enter text.
  5. Description of strain generation:Enter text.
  1. For Transgenic Strain Generation Only
  1. Genetic background:Enter text.
  2. Genetic insert description:Enter text.
  3. Strain nomenclature (if known, as described by the International Committee on Standardized Genetic Nomenclature for Mice):Enter text.
  4. Description of strain generation:Enter text.
  1. Strain Description
    What are the strain phenotypes and uses?Enter text.

12. For All Other Research Reagents (Plasmids, Recombinant Proteins, Cell Lines, etc.)
Additional Information
Please include any additional information about your reagent here:
Click here to enter text.
UNIVERSITY OF VIRGINIA CONTRIBUTORS–COMPLETE THIS SECTION
I (we) hereby certify that all of the information set forth in this disclosure is true and complete to the best of my (our) knowledge. I (we) have also specifically reviewed and agree with the percent contribution allocations set forth in Section 3 above.
Pursuant to the U.Va. Patent Policy, I (we) hereby confirm the prior assignment of all of my (our) right, title and interest to this intellectual property to the University of Virginia and agree to execute all documents as requested, to assign to the University of Virginia all of my(our) rights to any patent application filed on this intellectual property, and to cooperate with the University of Virginia and the University of Virginia Patent Foundation d/b/a the University of Virginia Licensing & Ventures Group (LVG) in the protection and commercialization of this intellectual property.Further, pursuant to the U.Va. Copyright Policy, I hereby acknowledge the University’s ownership of any copyrights in the intellectual property described and disclosed below. The University of Virginia will share any royalty income derived from the intellectual property with the inventor(s) according to its published policies.
SignatureDate
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E-mail Address
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Home Address (Street, City, State ZIP)
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E-mail Address
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Home Address (Street, City, State ZIP)
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SignatureDate
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E-mail Address
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Home Address (Street, City, State ZIP)
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E-mail Address
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Home Address (Street, City, State ZIP)
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SignatureDate
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E-mail Address
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Home Address (Street, City, State ZIP)
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Country of Citizenship / OFFICE USE ONLY
Pursuant to the memorandum of understanding between The Rector and Visitors of the University of Virginia (U.Va.) and the University of Virginia Licensing & Ventures Group (U.Va. LVG) effective July 1, 2011, U.Va. hereby assigns all of its right, title, and interest in this intellectual property to U.Va. LVG.
______
Executive Director, U.Va. Innovation
NON-U.VA. CONTRIBUTORS– COMPLETE THIS SECTION
I (we) hereby certify that all of the information set forth in this disclosure is true and complete to the best of my (our) knowledge. I (we) have also specifically reviewed and agree with the percent contribution allocations set forth in Section 3 above.
Please note that you may have an obligation to disclose and assign your rights in this intellectual property to your employer/institution. U.Va. LVG may independently contact your employer/institution to ensure appropriate disposition of all intellectual property disclosed on this form.
SignatureDate
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E-mail Address
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Home Address (Street, City, State ZIP)
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Country of Citizenship / SignatureDate
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Phone / Click here to enter text.
E-mail Address
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Home Address (Street, City, State ZIP)
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Country of Citizenship

(For disclosures with additional contributors, a supplemental signature page is provided at the end of this document.)

Page 1 of 5Revised 02/05/2013

Instructions

  1. The University of Virginia Licensing & Ventures Group (LVG) reviews all U.Va.intellectual property and research reagent disclosures as they are received from the U.Va.community. Where appropriate, LVG endeavors to license U.Va.intellectual property and research reagents to industry for further development and commercialization. Any royalties derived from any such license are shared with the inventor(s) and their labs, departments and schools according to theInnovation Revenue and Equity Distribution Formulas.This form notifies LVG of your research reagent and any relevant sponsorship, related agreements and publication history.
  2. The following instructions apply to the correspondingly numbered sections in the form:
  3. Use a brief descriptive title to aid in identifying the research reagent (i.e., “Protein X monoclonal antibody,” “Protein Y polyclonal antibody”).
  4. Provide a summary describing the generation and uses of your reagent. Note any purchased materials that are incorporated into your reagent, including genes for fluorescent proteins, proprietary reporter systems and commercial plasmids.
  5. Include the names of any potential co-inventors at U.Va. (top) and other institutions/organizations (bottom). A co-inventor is an individual who has conceived or contributed an essential element of the invention, either independently or jointly with others, during the evolution of the technology concept or reduction to practice.Include the percent contribution to the invention for each inventor as mutually agreed upon by all of the inventors.Absent agreement by all inventors to a percent contribution split that totals 100%, the LVG default position is to assume equal percent contributions for each inventor.
  6. List all sources of funding that relate to the creation/development of the intellectual property by providing the applicable contract or grant number(s), the funding agency and the principal investigator on the project(s), including departmental, governmental, industrial and/or foundation support (e.g., NIH, departmental, Coulter Foundation, other external sponsors, etc.).
  7. List all Material Transfer Agreements (MTAs) and other agreements wherein material and/or terms relate to the research reagent. Include materials received from non-U.Va. laboratories that are incorporated into your reagent.
  8. List any publications that describe the generation, use or characterization of your research reagent. Include links/URLs if available.
  9. A list of companies that may be interested in the invention will assist LVG in identifying potential licensees for the technology. Please include names and addresses of specific contacts if known.

Supplemental Signature Page

UNIVERSITY OF VIRGINIA CONTRIBUTORS – COMPLETE THIS SECTION
I (we) hereby certify that all of the information set forth in this disclosure is true and complete to the best of my (our) knowledge. I (we) have also specifically reviewed and agree with the percent contribution allocations set forth in Section 3 above.
Pursuant to the U.Va. Patent Policy, I (we) hereby confirm the prior assignment of all of my (our) right, title and interest to this intellectual property to the University of Virginia and agree to execute all documents as requested, to assign to the University of Virginia all of my(our) rights to any patent application filed on this intellectual property, and to cooperate with the University of Virginia and the University of Virginia Patent Foundation d/b/a the University of Virginia Licensing & Ventures Group (LVG) in the protection and commercialization of this intellectual property. Further, pursuant to the U.Va. Copyright Policy, I hereby acknowledge the University’s ownership of any copyrights in the intellectual property described and disclosed below. The University of Virginia will share any royalty income derived from the intellectual property with the inventor(s) according to its published policies.
Enter legal name hereSignatureDate
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Phone / Click here to enter text.
E-mail Address
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Home Address (Street, City, State ZIP)
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Country of Citizenship / Enter legal name here SignatureDate
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Phone / Click here to enter text.
E-mail Address
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Home Address (Street, City, State ZIP)
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Country of Citizenship
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Phone / Click here to enter text.
E-mail Address
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Home Address (Street, City, State ZIP)
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Country of Citizenship / Enter legal name here SignatureDate
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Phone / Click here to enter text.
E-mail Address
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Home Address (Street, City, State ZIP)
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Country of Citizenship
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Phone / Click here to enter text.
E-mail Address
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Home Address (Street, City, State ZIP)
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Country of Citizenship / OFFICE USE ONLY
Pursuant to the memorandum of understanding between The Rector and Visitors of the University of Virginia (U.Va.) and the University of Virginia Licensing & Ventures Group (U.Va. LVG) effective July 1, 2011, U.Va. hereby assigns all of its right, title, and interest in this intellectual property to U.Va. LVG.
______
Executive Director, U.Va. Innovation
NON-U.VA. CONTRIBUTORS –COMPLETE THIS SECTION
I (we) hereby certify that all of the information set forth in this disclosure is true and complete to the best of my (our) knowledge. I (we) have also specifically reviewed and agree with the percent contribution allocations set forth in Section 3 above.
Please note that you may have an obligation to disclose and assign your rights in this intellectual property to your employer/institution. U.Va. LVG may independently contact your employer/institution to ensure appropriate disposition of all intellectual property disclosed on this form.
SignatureDate
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Phone / Click here to enter text.
E-mail Address
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Home Address (Street, City, State ZIP)
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Country of Citizenship / SignatureDate
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Phone / Click here to enter text.
E-mail Address
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Home Address (Street, City, State ZIP)
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Country of Citizenship

(For disclosures with additional contributors, copy this page or contact the U.Va. Licensing & Ventures Group for additional pages.)

Page 1 of 5Revised 02/05/2013