CONFIDENTIAL
Intellectual Property Disclosure Form(Version II)
Patent, Copyright, Trademark and/or Others
This is a confidential, proprietary, nonpublic document that may NOT be communicated in any way without the written consent of the Qatar University’sInnovation & Intellectual Property Office (IIP Office). The completed form should be submitted to the QU IIP Office.
Please complete this form in its entirety. The IIP Officecannot process the application until it has been fully completed and signed by all contributors. Incomplete disclosure forms may be returned for resubmission. Please return this form and all supplementary material to:
Qatar University Innovation & Intellectual Property Office
Vice-President for Research and Graduate Studies
Qatar University
PO Box 2713
Doha/Qatar
1. Intellectual Property Title
Please provide a concise title for the Intellectual Property.
2. Contributors
List the names of all Qatar University and any non-Qatar-University personnel who contributed to this Intellectual Property. The Corresponding Contributor will be the contact person with regard to this Intellectual Property. Add rows if needed. Please indicate if any originators are not Qatar University employees. In such case, please indicate their corporate/university affiliation or Qatar University status, if any, (i.e. visiting professor, etc.). Indicate if any of the listed contributors have consulting or other relevant relationships with entities other than Qatar University. Please explain and attach any consulting agreements or other relevant contracts. Label these as Attachment A.
Note: Each contributor must sign this form.
Contributors (Indicating the Corresponding Contributor):
Contributor(s) Name(s) / Corresponding Contributor / Institution and Address / Email Address and Telephone Number / Home Address3. Sponsorship
Was the Intellectual Property conceived within the scope of a sponsored program (check one box)?
☐Yes☐No
If yes, List the names of all the funding agencies and programs below.
Funding Agency or Sponsor / Title of Project / Grant/Award Number / Subcontract?Yes or No / Awardee
4. Materials Used
Please describe any material used in the development of your Intellectual Property if that material was obtained from some source other than your laboratory or a commercial vendor. If agreements govern the use of that material, such as sponsored research agreement, material transfer agreement, please provide a copy if possible.
Material Description / Source / Governing Agreement / Remarks5. Detailed TechnicalDescription
Provide a brief description of the Intellectual Property, and address the following:
- What problems will it solve?
- Is it a new process, a composition of matter, a new device, or a new use for, an improvement of, an existing product or process, a software, a drawing, etc.?
- If the Intellectual Property is a composition of matter, a device, or a product, describe how it is made.
- If the Intellectual Property is a process, describe the steps that are involved.
- If the Intellectual Property involves advances over already existing intellectual property, please describe in detail any features which may distinguish this Intellectual Property from other inventions or technologies that may be similar in design or function.
Please attach a detailed technical description of the invention including its essential elements. The level of information required is such that somebody with a reasonable degree of technical knowledge could produce the same results as you. (Include drawings or photographs if applicable.)
3. Are there any possible variations or modifications that can be made to the invention?
6. Other Disclosures
Does this disclosure relate directly to any previous disclosures of Intellectual Property at Qatar University or elsewhere? If yes, explain.
7. Technology Key Words
List five to seven key words (separated with semicolons) that may provide searchable tags for your Intellectual Property.
8. Utility
What are possible uses or applications of this Intellectual Property? In addition to direct applications, are there any other uses that might be realized in the future?
9. Novelty
How does this Intellectual Property differ from existing technologies and current practices? What are its advantages and what problems does it solve?
10. Limitations
What are the disadvantages or limitations of this Intellectual Property? Can these be solved? How?
11. Experimental Verification
Have you tested the Intellectual Property experimentally, or have you constructed a prototype or model?
☐Yes☐No
If yes, describe below.
12. Prior Art
Are you aware of any inventions or publications by others that are related to this Intellectual Property?
☐Yes☐No
If yes, attach copies of any literature or patent searches that you have done. Include these as Attachment B.
13. Commercial Market
To the extend known, describe the current and/or potential market for this Intellectual Property. How do you envision that this Intellectual Property might be used in a commercial product or a process? Is there a suggested strategy for commercializing this Intellectual Property?
14. Industry Contacts
Please provide the names and contact information for the people with whom the QU IIP Office could discuss the commercial possibilities for this Intellectual Property. Mention if you have already spoken to any of these organizations. Please indicate if any of these organizations have expressed any interest in this Intellectual Property.
15.Risks
Identify and explain the risks (technological or otherwise) that could jeopardize the commercialization of this Intellectual Property. Describe the greatest impediment to the adoption of your Intellectual Property.
16. Non-Confidential Abstract
Provide a brief (less than one page) abstract of the Intellectual Property. Note that this abstract SHOULD NOT CONTAIN CONFIDENTIAL INFORMATION and is intended for marketing purposes. Therefore, it could be distributed without a non-disclosure agreement. It is important to include the novel nature of the Intellectual Property. However, this should not include elements that would allow someone to practice or reproduce this Intellectual Property.
17. Public Disclosures: Publications, Oral Presentations, Posters, Web Postings
A public disclosure may impact the kind of patent rights that may be obtained for your technology, should the technology be patent-eligible. Please notify the IIP Office immediately if the technology becomes, or, preferably, is about to become, published or otherwise publically disclosed to minimize loss of intellectual property rights.
A)Has your Intellectual Property been disclosed publicly (ex: publication, meeting abstract or presentations)?
☐Yes☐ No
If yes, please list the titles and dates of public disclosures of the Intellectual Property. This includes publications, oral presentations, posters, theses, websites, or speaking to the press or media. Indicate whether the Intellectual Property was described in specific or general fashion. Include copies of publications, abstracts of talks, news stories, etc. Label them collectively as Attachment C.
B) Are there planned future publications or public disclosure?
☐Yes☐No
If yes, please include a date when the publication will be distributed or the date when any public disclosure such as a talk will take place. Include copies as Attachment D.
Disclosure Description(s) / Planned Dates of Disclosure18. Contributors’ Information
Name / Last / First / Title (Dr./Ms./Mr.)Employer and address:
Position:
Home address:
Telephone number:
Email:
Citizenship:
Please read and affirm the following statement by signing below:
To the best of my knowledge, I confirm that the subject matter disclosed herein is accurate and original to me. I understand that I am subject to the Qatar University’s policies, including the University’s Intellectual Property policy.
Signature / Date
Name / Last / First / Title (Dr./Ms./Mr.)
Employer and address:
Position:
Home address:
Telephone number:
Email:
Citizenship:
Please read and affirm the following statement by signing below:
To the best of my knowledge, I confirm that the subject matter disclosed herein is accurate and original to me. I understand that I am subject to the Qatar University’s policies, including the University’s Intellectual Property policy.
Signature / Date
Name / Last / First / Title (Dr./Ms./Mr.)
Employer and address:
Position:
Home address:
Telephone number:
Email:
Citizenship:
Please read and affirm the following statement by signing below:
To the best of my knowledge, I confirm that the subject matter disclosed herein is accurate and original to me. I understand that I am subject to the Qatar University’s policies, including the University’s Intellectual Property policy.
Signature / Date
Qatar UniversityConfidentialIP Disclosure FormPage 1/1