UCT Material Disclosure Form

Department of Research & Innovation

Research Contracts & IP Services

University of Cape Town. Private Bag.Rondebosch.7701.South Africa

Research & InnovationBuilding.2 Rhodes Avenue.UCT.Mowbray.7701

Fax: +27 (0)21 650 5778.Tel: +27 (0)21 650-3355

MATERIALDISCLOSURE FORM

This form needs to be completed prior to the drafting of a Materials Transfer Agreement – for material that is being transferred OUT of UCT. Its primary purpose is to identify beneficiaries in terms of commercialisation and to verify the ownership of the material by UCT – i.e. to ensure that no other party has claim to ownership (e.g. provider of material that genetic material was isolated from, funder, co-creator on a collaborative project, etc.) or that permissions need to be sought (often a funder requirement).

In terms of the UCT IP Policy

“Tangible Research Property” means tangible results arising from research

activities, such as but not limited to: prototypes, drawings and diagrams, biological

organisms and material, reagents, integrated circuit chips, software and data (and UCT claims full ownership of Tangible Research Property that is not co-owned, or where ownership has been assigned to a third-party by UCT in terms of an Agreement)

For any questions please contact:l021 650-2425

tel 021 650-3076

IP Services Reception tel021 650-4015

DateSubmitted: {Please submit electronically in Word format}

Short Name for the Material:

Primary Contact:

Do any of the Creators work in an MRC-funded Group, Unit or Centre? Yes / No

Creator/s

PLEASE ADD ADDITIONAL TABLES FOR INVENTORS AS NECESSARY – Include Creator from other institutions – note their affiliation in Department & Group/Unit field.

If you leave UCT, please keep our office updated as to your contact details so that we can track you for the payment of any royalty income accruing to the creators.

*

FULL names[as per ID document] / Ensure your FULL names are included here, e.g. your middle name, as they appear on your ID document / birth certificate. Delete this text.
Title [Mr/Ms/Prof/Dr]
Department & Unit/Group
Faculty
Staff or Student Number
Tel no.
Cell no.
Email address
Residential Address
Postal address & code if external, or UCT internal mail delivery address.
Nationality
FULL names [as per ID document] & title: / Ensure your FULL names are included here, e.g. your middle name, as they appear on your ID document / birth certificate. Delete this text.
Department & Unit/Group
Faculty
Staff or Student
Tel no.
Cell no.
Email
Residential Address
Postal address & code if external, or UCT internal mail delivery address.
Nationality

Share in Intellectual PropertyCreation(add more rows if necessary)

Name / Institution / Company* / % Share[1]
100

*Note UCT inventors should record “UCT” in the Institution column.

What is the name of the project that the material arose from?
Who is the Principal Investigator / Lead on the project?
Who funded the project? Include contract number or fund number if available.
What is the approximate date of creation of the material?
Nature of the material
(e.g. microoganism, genetically modified organism, virus, plasmid, vector, DNA, hybridoma, monoclonal antibody, etc.)
Description of the material
(this needs to precise as possible as this will be used to define the material in a Materials Transfer Agreement)
What was the material created from / its source?
E.g. A microoganism was isolated from a soil sample received from a field in Pinelands, South Africa. A virus was isolated from a plant sample that was received from Starburst Nursery, Cape Town, South Africa
Who provided the access to the ‘source’?
Do they have any claim to the material that has been isolated/derived?
Reference number(s) associated with the material (could be a culture collection number, strain identification code, etc.)
Does any part of the current material include material that is owned by other parties?
If so, provide details. Also indicate whether there are specific rights associated with that material / an associated Material Transfer Agreement.
E.g. a plasmid may have been obtained from an institute and it has been inserted into a Genetically Modified Organism that is being disclosed on this form

Where for example a number of materials are being disclosed, please insert a table to summarise the details – e.g. a list of microorganisms and their numbers that form part of a ‘set’ to be transferred or a culture collection.

Use of Biological (or other) Materials

Is the material:

i) based on, or derived from, a South African indigenous biological resource of a genetic resource?

Yes / No

ii) based on, or derived from, traditional knowledge or use

Yes / No

iii) co-owned with the local community or individual

Yes / No

This may trigger other Biodiversity Act compliance requirements and permit requirements associated with Materials Transfer – even if only intedended for academic/research use.

RCIPS Assessment Notes

[Name of RCIPS person who conducted due diligence: ]

Research Contracts & IP Services (Oct2011)Page 1 of 4

[1]This share is the basis on which the Creators’ portion of possible royalty income will be shared. A default situation is where the inventors elect to share the proceeds equally. It should correspond to the contribution made to the creation of the IP.