Confidential - OTC staff use only:

Docket #:

INTELLECTUAL PROPERTY DISCLOSURE FORM

Time-Sensitive Material, Please Expedite

This is a confidential, proprietary, nonpublic document that may not be communicated in any way without the consent of the University’s Office for Technology Commercialization (OTC).

E-mail or send the completed form and all attachments to:

Office for Technology Commercialization

Attn: Contracts Manager

1000 Westgate Drive, Suite 160

Campus mail:delivery code 2431

St. Paul, MN 55114

Phone:612.624.0550

E-mail:

Web site:

Please type. If you require more space, please attach additional pages with reference to the continued item. This form is available as an electronic file you can download from

Please contact OTC at 612.624.0550 or with questions about this form.

Upon request, OTC staff will send a copy of this form to the department chair(s) and the dean(s) of the college(s) in which the inventor(s) developed the technology.

1.Intellectual Property Title and Description.

1.1Intellectual Property title:

1.2Describe the key features of your Intellectual Property:

1.3What are the applications of this Intellectual Property?

1.4How is this Intellectual Property different from existing technology?

1.5Why is this Intellectual Property better than existing technology?

1.6Please list key words to use in patent and literature searches:

1.7What is the stage of development of this Intellectual Property?

2.Contributors. Please list every person who provided any intellectual input in developing this Intellectual Property (including students, post-doctorates, scientists and non-University of Minnesota personnel). The University and its counsel will use this information to determine inventorship or authorship in accordance with the law applicable at the time the University decides to seek intellectual property protection.

Please inform OTC of any changes in the information below.

2.1Name: / Department:
Work Address:
Work Phone: / Work Fax:
Work E-mail:
2.2Name: / Department:
Work Address:
Work Phone: / Work Fax:
Work E-mail:
2.3Name: / Department:
Work Address:
Work Phone: / Work Fax:
Work E-mail:
2.4Name: / Department:
Work Address:
Work Phone: / Work Fax:
Work E-mail:
2.5Name: / Department:
Work Address:
Work Phone: / Work Fax:
Work E-mail:

3.Public Disclosure or Public Use/Sale. List the titles and dates of possible public disclosure of the Intellectual Property (past or future) and attach copies of published or submitted versions. Public disclosure includes any papers, theses, conference presentations, posters, and Web sites anywhere in the world describing all or part of this Intellectual Property. The public disclosure date is the date the material was or will be available to others (people not affiliated with the University of Minnesota, excluding editors, conference sponsors, or others involved in preparing the article or presentation).

For example, public disclosure occurs when a journal is first mailed, when information is first posted to the Web, when a thesis is catalogued, or when conference participants may obtain an abstract. If you are not certain when a future public disclosure may occur, please estimate the earliest date possible and mark as ESTIMATE. Please inform OTC of any changes in public disclosure dates.

Describe all previous or planned public or commercial use/sale and give the date of such use. Please list all companies, firms, research firms, universities, and groups you provided the know-how or product for use.

Papers (including manuscripts, letters, and abstracts): / Date:
Presentations and posters: / Date:
Theses: / Date:
Web sites: / Date:
Other public disclosures: / Date:
Public or commercial use/sale description: / Date:

4.Funding. List all sources of funding (external and internal) related to the conception and development of this Intellectual Property. It is important this information is accurate and complete because sponsors may have certain rights in the Intellectual Property.

Source: / Agency Grant No: / University CUFS No:

5.Prior Art. Attach copies of any literature and patent searches you have done, articles you have published and any articles, patents and product descriptions concerning technologies closely related to this Intellectual Property. A survey article on the field of the Intellectual Property is particularly useful. Please list all people that you know of who are working on or have worked on research similar to this Intellectual Property.

6.Commercial Market. To the extent known, describe the current and/or potential commercial market for this Intellectual Property. There will be no disclosure of proprietary information during these conversations without protection for the confidentiality of the disclosure.

7.Industry Contacts. Please provide the names and telephone numbers for any contacts in industry with whom an OTC representative could discuss the commercial possibilities for this Intellectual Property. (List complete name, company mailing address, phone and fax numbers, e-mail address, and Web site for each contact.)

Contact / Company / Address / Phone / Fax / E-mail / Web Site

Form: OGC-SC412

Form Date: 05.22.02

Form Revision Date: 06.11.07

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