INVENTION DISCLOSURE FORM

DISCLOSURE DATE:Click here to enter a date.

INVENTION TITLE

INVENTOR DETAILS

List all persons who have directly contributed in the development or conception of the invention. If there are more than 3 inventors, please use a separate sheet.

INVENTOR 1
(Lead Inventor*) / INVENTOR 2 / INVENTOR 3
FULL NAME
CC DEPARTMENT & INSTITUTE
HOME ADDRESS
PHONE
EMAIL
COUNTRY OF CITIZENSHIP
EMPLOYEE #
DATE OF BIRTH
% CONTRIBUTION**
SIGNATURE
DEPARTMENT CHAIR / DEPARTMENT/DIVISION / DATE / SIGNATURE

*The Lead Inventor will be Innovations’ main contact for the invention and is responsible for sharing correspondence with other inventors listed on this document and assisting in the completion of tasks.
**% Contribution indicates the percentage that each inventor would receive from the inventor portion of commercialization revenue, if any, as provided in Cleveland Clinic’s Intellectual Property and Commercialization Policy in effect at the time of invention disclosure.
Assignment: By signing this invention disclosure, each inventorwho is considered “CCF Personnel” under Cleveland Clinic’s Intellectual Property and Commercialization Policy hereby assigns all rights, titles and interests to The Cleveland Clinic Foundation and denotes that the inventor also agrees to cooperate in the filing of patent applications and the commercialization of the technology.

Send the completed, signed form and all attachments to:

or Cleveland Clinic Innovations GCIC-10

Invention Disclosure Form

Invention Domain (select one)

☐Medical Device☐Health Information Technology

☐Therapeutics & Diagnostics☐Delivery Solutions (Clinical/Business Know-how)

1a. Provide a description of the invention. (Attach or embed Images or other relevant documents upon submission)

1b. Please provide a bulleted list of the key novel features of this invention.

2. Have you received any grant funding that is associated with this invention?

☐Yes☐No

*CC is required to report government funded inventions to relevant funding agencies and provide a written description of the invention in technical detail. Noncompliance with federal reporting requirements may result in the termination of grant funding. Please see link for our obligations under the Bayh-Dole Act.

If Yes, please provide the below information:

Grant Number (s) / Amount(s) Awarded / Funding Source(s)

3. What problem or clinical indication does the invention intend to address?What are the advantages of the invention over other known technologies or solutions?Please list.

4. Please describe the current Stage of Development & Technical Feasibility:

5. Has this invention been publically disclosed? If yes, please explain.

6. Please list any industry contacts or potential licensees that could be pursued for this invention.

7.Please list any known publications or intellectual property that are relevant to your invention.

Send the completed, signed form and all attachments to:

or Cleveland Clinic Innovations GCIC-10