Scott & White Innovations

SCOTT & WHITE HEALTHCARE INVENTION DISCLOSURE FORM

Please Read: The information requested in this Invention Disclosure Form is required underthe Scott & WhiteHealthcare Intellectual Property Policy toassess the disclosed technology. Your invention disclosure is a legally important document that should be prepared carefully. This form must be completed in its entirety. Incomplete forms may be returned for completion and resubmission.

Title of Invention:

Please provide the name of each person whom you believe might have contributed to the conception of the disclosed invention and their affiliation (S&W, TAMU, HSC, VA). If any contributor has a joint appointment with another institution, please list each appointment below. Check the box corresponding to the Lead Contributor. (Lead Contributor indicates the primary contact person).

Lead Name and Affiliation

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Invention Description/Abstract. Please describe the invention or discovery that you are disclosing.

Purpose. Please describe the purpose of this invention or discovery.

Advantages. Please describe the key features or advantages of this invention or discovery, and how it achieves its advantages.

Stage of Development. Briefly discuss the current status of your invention (e.g., theoretical or conceptual; supported by laboratory results; prototype under development; prototype completed).

Funding. THIS SECTION MUST BE COMPLETED. IF YOU CHECK ‘YES’, YOU MUST ALSO COMPLETE THE BOXES BELOW. Rights in inventions may be impacted by the sources of funding used to develop them. Please list all sources of funding used in the conception and development of the invention/discovery; include grant numbers or other unique identifiers for each.

Was the conception or development of this invention or discovery funded in any way by an internal or external source?

YES NO

Note: Types of funding sources include but are not limited to federal agencies, state agencies, i.e. internal funds, non-profit research foundations, private companies, and providers of gift contributions.

Name of Funding Agency / Federal Grant/Other Award Reference No. / Internal Reference Number / Office/Person Managing Grant/Award

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Materials/Information Used. Rights in inventions may be impacted by materials of others used to develop them (e.g., materials obtained under a Material Transfer Agreement; materials sent by a colleague at another institution; purchased materials for which there was a purchase agreement; information obtained under a Nondisclosure Agreement; information received from an outside party under terms of confidentiality).

a.Was this invention derived from materials received from another investigator or from a company? YES NO

b.Has the invention been transferred to any third party under a material transfer agreement or other agreement? YES NO

c.Is this invention related in any way to contractual agreement that any of the contributors to the invention have with a company or other institution? YES NO

If answer to any of the above is “YES,” please add detail here:

Outside Relationships or Agreements. Other than Material Transfer Agreements, please provide information on any other relationships or formal agreements with outside parties that may relate to this technology.

a.Is this invention related in any way to a consulting agreement that any of the contributors to the invention have with a company? YES NO

b.Are any of the contributors to the invention involved in a clinical trial related to (1) this invention or (2) technology (drug, device, etc.) in the same field or class as the YES NO

If answer to any of the above is “YES,” or if you are unsure, please add detail here:

Prior Public Release of Information. Release of information about an invention or discovery can impact the scope of intellectual property rights that can be obtained. Please check the boxes of the types of disclosures (oralor written) that have occurred that mention or describe the invention or discovery. Below each checked box, please provide the earliest date of occurrence and a brief description what information was made publicly available.

Check and describe all that may apply.

No public release of information

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Published abstracts or manuscripts. If checked, please provide date of publication:

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Abstracts or manuscripts submitted for external review but not published. If checked, please

provide date of submission:

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Web publication. If checked, please provide date of publication:

Conversation or e-mail with external party. If checked, please provide date of conversation or

email:

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Presentation outside of department. If checked, please provide date of presentation:

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Thesis or Dissertation. If checked, please provide earliest date of presentation or publication:

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During consulting. If checked, please provide earliest date of disclosure:

Other. Please provide details:

Planned Release of Information. Please provide the estimated date and description of any planned publications or public releases of information about this invention or discovery.

Commercial Interest. Please list any entity (person or company) that may be interested in commercializing this idea. If you are interested in creating a start-up company, please let us know.

10. Earliest date of conception:

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CONTRIBUTOR DATA SHEET

Please complete a Contributor Data Sheet for each person named in section 1 and 2 of thisInvention Disclosure Form. Additional forms may be found at the Inventions website (click here or go to (Note that the Signature Page (next page) must be printed, signed and submitted when the Invention Disclosure Form and Contributor Data Sheet(s) are submitted.)

Contribution:

Briefly describe your contribution to the disclosed invention.

% contribution relative to other listed contributors:1

Inventor:

Preferred Salutation: Professor Dr. Ms. Mrs. Mr. Other

First: MI: Last: PhD MD DPM Other:

Work / Home
Address: / Address:
Phone: / Phone:
Fax: / Fax:
Email: / Email:

Country of Citizenship:

Department/Division:

Non-S&W Healthcare Employment Status/Title (for persons who are NOT employees of an Scott & White Healthcare or one of its affiliate entities):

Please provide your Position/Title and Company/Institution Name:

SIGNATURE PAGE

All contributors must sign this form acknowledging that they have read, understood, and accepted it as written, including the percentage inventive contribution section (above).

SignatureDate

Note: Please insert additional signature lines as needed.

Please contact us at 254-724-5491 with any questions concerning this Invention Disclosure Form. Please email the completed Invention Disclosure Form and all Inventor Data Sheets to or mail to the address below:

Attn: Cheryl Perkins

MS-20-D642

2401 S. 31st St.

Temple, TX 76508

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