Office of Technology Commercialization Invention Disclosure Form

Office of Technology Commercialization Invention Disclosure Form

InventorInformation

Disclosure Title:

Short (Non-Confidential) Title:

Primary Inventor Name:

Primary Inventor’s Percent Contribution:

PrimaryInventor'sDepartment:

Please list any additional inventors and their percent contribution:

InventionRelatedDates

ConceptionofInvention (date):

Dowrittenrecordsexist?(Y/N):

Ifyes,pleaselistthelocationofthewrittenrecords.If no, please list the names of the individuals with

whomyouhaddiscussions:

Isthereexperimentalevidenceoftheinvention?(Y/N):

Ifyes,pleaselistthelocationofthewrittenrecords.If no, please list the names of the individuals with whomyouhaddiscussions:

Description

ConfidentialDescriptionofInvention

Pleasedescribetheinventioncompletely.Includesketches,drawings,andphotographsasappropriate.

Providekeydataandexperimentalresults.Ifavailable, includeadraftmanuscript,PowerPointslides,video,spreadsheets,andanyadditionaldocumentationrelevanttothedisclosure.

Appointment/Membership

Pleaseindicateanyappointments/memberships/affiliationsyouhadatthetimeoftheinvention:

TechnicalSummary

Pleasecommunicate a concise technical summary ofthe invention.Useextraspaceifneededandappendcompletedescriptions(e.g.data,publications,abstracts,graphs,presentations,etc.).AllattachmentsshouldbeincludedintheDocumentssectionbelow:

Advantages

Whataretheadvantagesofyourinventionoverthecurrentstate-of-the-art?

Whatarethepracticalandcommercialapplicationsoftheinvention?

Development

StageofDevelopment

Pleaseindicatethestageofdevelopmentofyourinvention:(e.g.concept,earlystage,benchprototype,industrialprototype,product,market,etc.):

NextSteps

Pleaseindicateyournextsteps.:

AdditionalResources

Pleaseindicateadditionalresourcesneeded:

Doestheinventionpossessdisadvantagesorlimitations?(Y/N):

Ifyes,pleasedescribe:

Howmightthese beovercome?

Marketing

MarketingTargets

Pleaselistanycompaniesyoubelieveare/mightbeinterestedinyourinventionintheMarketingTargetssectionbelow:

OutsidePartyKnowledge

HavetheessentialelementsoftheinventionbeendisclosedtoanyoneoutsideoftheUTHSCSAeitherorallyorinwriting?(Y/N):

Ifyes,towhom?

PublicDisclosure

Doyouintendtopubliclydisclosetheessentialelementsoftheinventioninthefuture,eitherorallyorinwriting?(Y/N):

Ifyes,pleaselisthow.(E.g.publication,thesis/dissertation,seminar,poster,meeting,abstract,webpage,etc.):

FundingSources

WasresearchonthisinventionfundedbyagovernmentagencycontractorCPRITgrant?

If yes, pleaselisttheoutsidefunding sources. Please be sureto includethe GrantorAccountnumber:

VA Affiliation

Do you have a Veteran’s Administration (VA) Appointment?

If yes, is your VA Appointment without compensation (WOC)?

Materials

Didthisinventionutilizedataormaterialsfromanyofthefollowing? (Please indicate all that apply):

MTA (Material Transfer Agreement)

CRADA/SBIR/STTR

Biological Materials (e.g., human blood, tissues, or cell lines)

Cancer Therapy & Research Center (CTRC)

Ifothers,pleaselist:

Students

PleaselistanyinventorswhowerestudentsattheUTHSCSAduringtheconceptionanddevelopmentoftheinvention.(listnames):

Colleagues

Please list any colleagues on campus who are knowledgeable about the work and its potential impact.(listnames):

ExternalResearchers

Pleaselistexternalresearcher(s)/competitor(s)whoworkinthefield(s)relatedtothisdisclosure:

Non-confidentialSummary

CommercialSummary

Pleaseprovideanon-confidential,simple,andcommerciallyapplicablesummaryoftheinvention.Thiswillbeusefulformarketingpurposes;includeadvantages,characteristics,andindustryapplications.

______

Primary Inventor SignatureDate

______

Additional Inventor SignatureDate

______

Additional Inventor SignatureDate

______

Additional Inventor SignatureDate

Please include any documents that you feel may be relevant to the invention when you return this form to OTC.

Return this signed form by email to

Office of Technology Commercialization, 8403 Floyd Curl Drive, Mail Stop 7746, San Antonio, TX 78229

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