TECHNOLOGY DISCLOSURE FORM



SOFTWARE OR APP DISCLOSURE FORM

UCSF Innovation Ventures – Office of Technology Management

Case No:

Licensing Officer:

Description

1. How would you categorize the material you are disclosing?

Software code

Mobile App

Software idea or algorithm (not fully coded)

Other __________________________________________

2. Provide the full name of the software/app you are disclosing to our office. There should be one unique piece of software or one app per disclosure.

3. Is the software or app fully developed, or are additional resources required for commercial or public use?

4. Year code was completed:

Year code was first published:

Where published:

Has the source code been distributed in any other form? If yes, please explain.

5. UCSF authors/developers:

Name Position Dept Contact Info

6. Non-UCSF authors/developers:

Name Position Employer Contact Info

7. For non-UCSF authors:

a. Was the software/app developed under a contract with UCSF?

Yes

No

If Yes, please provide details, and contracts if available.

b. Was the software/app developed using any non-UCSF funds?

Yes

No

If Yes, please provide details

8. If any author/developer is a member of or has affiliation with any of the following organizations, please check the appropriate box and provide any relevant information that might be useful for us to determine UCSF’s obligations:

Chan Zuckerberg BioHub

HHMI (Howard Hughes Medical Institute)

PICI (Parker Institute for Cancer Immunotherapy)

VA (US Department of Veteran Affairs)

CDMI (Center for Disruptive Muscuoskeletal Innovations)

9. Please provide a list of all third party code embedded in or accessed by the disclosed software when it is run. Please include all open source, free executable, public domain, library, and all other executable or source code not written by the authors mentioned above. ALL AUTHORS MUST DISCLOSE ALL OF THE THIRD PARTY CODE AND MATERIALS THAT HAVE BEEN EMBEDDED IN THE SOFTWARE. Software code and Materials easily available for download and available without cost are NOT free. These codes and Materials are restricted by licensing terms that must be reviewed and complied with. All code and Materials included in the software that were not developed by the authors must be listed in the Software Disclosure. Also list any code or Materials with which the software automatically links, executes, or integrates that may not be embedded in the software.

Name of third party code Web page to download Location of license

10. Does your software or app have any specific hardware requirements? Please explain.

Advantages

In this section, please help us understand the usefulness and unique value of the software.

11. How would a recipient use the software or app?

12. Why did you develop this software rather than use something previously available?

Companies

13. Please list any companies that might be interested in this software or app

Funding Sources

Provide each full contract or grant number used in the development of this software. Please include industry sponsored research, non-profit funding, governmental funding, applicable fellowships, etc.

| | |Principal Investigator/ |

|Funding Source/Sponsor |Contract or Grant Number |Supervisor or Fellow to whom awarded |

| | | |

| | | |

| | | |

Chan/Zuckerberg Biohub Obligations

1. Was this software/app developed using i) Chan/Zuckerberg BioHub facilities, ii) UCSF equipment purchased or maintained using BioHub funding, or iii) UCSF supplies obtained using BioHub funding?

Yes

No

I don’t know

If yes, was the use of these facilities, equipment, or supplies important, material, or significant to the development of this work?

Yes

No

2. Was this software/app developed using Chan/Zuckerberg BioHub funding?

Yes

No

I don’t know

If yes, was the funding used to perform activities important, material, or significant to the development of this work?

Yes

No

Signature

Please have all developers sign this form.

I HAVE FULLY DISCLOSED ALL OF THE THIRD PARTY CODE AND MATERIALS THAT HAVE BEEN EMBEDDED IN THE SOFTWARE DESCRIBED IN THE PRESENT DISCLOSURE.

I HEREBY ASSIGN ALL RIGHT, TITLE, AND INTEREST, INCLUDING BUT NOT LIMITED TO COPYRIGHT AND COPYRIGHT RIGHTS, PATENT RIGHTS AND PROPERTY RIGHTS, IN THE INVENTION DISCLOSED HEREIN TO THE REGENTS OF THE UNIVERSITY OF CALIFORNIA.

Developer’s Signature:

Print Name:

Date:

Developer’s Signature:

Print Name:

Date:

Developer’s Signature:

Print Name:

Date:

Principal Investigator Signature

Note: Only have PI sign here if the PI is not an inventor and did not sign above.

Principal Investigator’s Signature:

Print Name:

Date:

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