Technology Transfer Office of Research Florida State ...



Florida State University ( Office of Commercialization

WORK DISCLOSURE FORM

This form is used to disclose a University-supported work(s), generally, Copyrightable materials, as required under Florida state university (fsu) policies (explained in Policy on University-Sponsored Educational Materials (Copyrights)). Inventions, generally Patentable materials, should be disclosed on the form entitled Invention Disclosure Form. All Questions are important so please respond to each even if the answer is "none" or "Not Applicable". For questions regarding this form, please call the office at (850) 644-9318.

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|I. Description of Work(s) |

|Title of Work |

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|Description (book, computer game, sound recording, sculpture, etc.). Please provide a copy of the work, if possible. |

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|Please check the box that best describes this work |

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|This Work is: |

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|Entirely original |

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|A collaboration |

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|Co - Author: ____________________________ Co - Author: ___________________________ |

|Co - Author: ____________________________ Co - Author: ___________________________ |

|Co - Author: ___________________________ Co - Author: __________________________ |

|Co- Author: ____________________________ Co - Author: __________________________ |

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|A compilation or derivative Work |

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|II. Publications, Public Use and Sale |

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|Has the Work been offered to a publisher or journal? |

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|Yes No |

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|If Yes, please provide the name of the publisher or journal: ___________________________ |

|Has the Work been accepted? Yes No |

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|If Yes, Please attached the proposed Publishing Agreement |

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|III. Sponsorship and Support |

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|If the research that led to the Work(s) was sponsored, please fill in the details and attach a copy of the |

|contract or agreement if possible |

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|Please list all University facilities and materials budgeted for the development of the Work(s). Hours and costs are approximate. Please |

|include any release time, student salaries, special services, and subcontracts that were budgeted for. |

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|Facility/material/personnel Dates Total hours (approx.) Costs (approx.) |

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|___________________________ ______________ ________________ ____________ |

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|___________________________ ______________ ________________ ____________ |

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|___________________________ ______________ ________________ ____________ |

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|___________________________ ______________ ________________ ____________ |

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|___________________________ ______________ ________________ ____________ |

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|Total Costs: _________ |

|If any of the University support described above was through an internal or external grant or contract, please provide the following information |

|for each such contract or grant. |

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|PI Name: _________________________________ PI Name: ____________________________________ |

|Grant/ Contract #: __________________________ Grant/ Contract #: _____________________________ |

|Grant/ Contract Title: ________________________ Grant/ Contract Title: _________________________ |

|Grant/ Contract Awarded: $ __________________ Grant/ Contract Awarded: $_____________________ |

|Did you or any of the authors use material from others (such as software or manuscripts) to produce the Work? |

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|Yes No |

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|If Yes, please provide the permission source. |

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|IV. Economic/Market Information |

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|How do you expect this Work will be used in the market (e.g. journal article, textbook, instruction, training, performance, computer |

|applications, etc.) |

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|Please give your best guess as to the economic potential of this invention if any, when used as you expect in A. |

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|Less than $10,000 $10,000-$100,000 $100,000-$1 million over $1million |

|Please give us any other pertinent information not covered elsewhere that may provide guidance to the decision-making process and optimal |

|utilization of the technology. |

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|V. For Our Records |

Please list the names and titles of all authors (print; sign where indicated). All Fields are required. For an explanation of authors and co-authors please click here. If An Author is not an FSU Employee please attach any governing agreements.

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|Name____________________________ Signature___________________________ Date___________ |

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|Department_____________________________College_________________________________________ |

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|Business Address___________________________________ Business Phone______________________ |

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|Business Fax______________________________ e-mail ______________________________________ |

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|Home Address_____________________________________ Home Phone________________________ |

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|Social Security Number_______________________ |

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|Citizenship_________________________________ |

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|Name____________________________ Signature___________________________ Date___________ |

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|Department_____________________________College_________________________________________ |

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|Business Address___________________________________ Business Phone______________________ |

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|Business Fax______________________________ e-mail ______________________________________ |

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|Home Address_____________________________________ Home Phone________________________ |

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|Social Security Number_______________________ |

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|Citizenship_________________________________ |

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|Name____________________________ Signature___________________________ Date___________ |

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|Department_____________________________College_________________________________________ |

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|Business Address___________________________________ Business Phone______________________ |

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|Business Fax______________________________ e-mail ______________________________________ |

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|Home Address_____________________________________ Home Phone________________________ |

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|Social Security Number_______________________ |

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|Citizenship_________________________________ |

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|Name____________________________ Signature___________________________ Date___________ |

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|Department_____________________________College_________________________________________ |

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|Business Address___________________________________ Business Phone______________________ |

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|Business Fax______________________________ e-mail ______________________________________ |

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|Home Address_____________________________________ Home Phone________________________ |

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|Social Security Number_______________________ |

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|Citizenship_________________________________ |

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|Name____________________________ Signature___________________________ Date___________ |

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|Department_____________________________College_________________________________________ |

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|Business Address___________________________________ Business Phone______________________ |

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|Business Fax______________________________ e-mail ______________________________________ |

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|Home Address_____________________________________ Home Phone________________________ |

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|Social Security Number_______________________ |

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|Citizenship_________________________________ |

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|VI. Department Information |

The department chairperson and Deans of each inventor should sign to confirm the University contribution, and Contract and Grant support, to the Creative Work(s). Copy this page for additional Chair or Dean signatures if needed.

|Signature of Department Chairperson(s) |

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|Chair 1 |

|Chair 2 |

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|Department |

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|Printed |

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|Signature |

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|Date |

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|Signature of Dean(s) |

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|Dean 1 |

|Dean 2 |

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|Department |

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|Printed |

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|Signature |

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|Date |

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|Mail or Hand-deliver this form to: |

|The Florida State University |

|Office of Commercialization |

|95 Chieftan Way, 312 Dittmer Building |

|(Across from the Dirac Science Library) |

|Tallahassee, FL 32306-4391 |

|Phone: 850/644-9318 |

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|Copyright © 2001-2014. The Florida State University. |

|All rights Reserved |

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|Last revised 8/29/2014 |

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Percent Share of Inventor Royalties____________

Percent Share of Inventor Royalties____________

Percent Share of Inventor Royalties____________

Percent Share of Inventor Royalties____________

Percent Share of Inventor Royalties____________

The University asserts or waives its interest in the work(s) as disclosed:

Asserts_________________ Waives___________________

VP for Research or designee___________________________ Date_________________

(Office use only)

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