TECHNOLOGY DISCLOSURE FORM



INVENTION DISCLOSURE FORMUCSF INNOVATION VENTURES – OFFICE OF TECHNOLOGY MANAGEMENT INVENTION DESCRIPTION AND COMMERCIALIZATIONIn this section you will provide details about your invention to help us better understand it and its commercial potential. Invention Title: One paragraph summary description of your invention. [If your invention has resulted from use of any Federal Government funding, please attach a detailed description (with drawings if applicable) and a manuscript, if available, as required by the Federal Government. This will help UCSF to meet its obligations to the Federal Government.]Please identify the commercial products or services a company could develop from your invention (think broadly). What is the unmet need that your invention/product addresses and who are the likely customers (note there may be more than one customer type – e.g. research reagent and therapeutics)? What aspects of your invention/product are novel improvements over existing technologies?What advantages will a product developed with your technology have over current technologies or products? List any relevant competing technologies and products and the corresponding companies offering those products.Has the invention/product been reduced to practice (made and tested)? If not, what stage is your invention/product at?What are the steps required to bring your product or service to market? 10. Are you aware of any companies that would be good commercialization partners for your invention? Please list and include any contacts.11. Are you interested in starting a company around your technology?12. Have you worked with any other groups at UCSF to further your technology (e.g. Catalyst, QB3, Alliance Management, Entrepeneurship Center, CDHI etc.)? 13.Have you discussed the invention with any companies? If so, please list and include your contact there. TIMELINE OF EVENTSThis section is critical for us to understand what deadlines may be associated with this invention and whether patent rights are available. Note that you should alert our office well in advance of any pending public disclosure so that we can make informed decisions regarding patent protection. Please note: submission of an invention disclosure form to our office does not constitute filing a patent application.First description of complete invention, oral or written (conception)Date:Reference and comments including location of any written documents:First successful demonstration or reduction to practiceDate:Reference and comments including location of any written documents:Has the invention been publicly disclosed? A public disclosure can include a publication, abstract, thesis, poster presentation, oral presentation, awarded NIH grant, web postings (including social media posts and lab websites), or conversation with persons outside of UCSF that include enough details to understand and replicate the invention. FORMCHECKBOX Yes (be sure to include copies of any publications) FORMCHECKBOX NoIf the invention has been disclosed, provide the exact date and source/reference of the disclosure. Note that this date establishes the bar date or deadline for filing a patent application. When will the invention be publicly disclosed in the future? Provide details of the timing and type of planned disclosure (e.g. manuscript, abstract, thesis, project report, etc.). CHAN/ZUCKERBERG BIOHUB OBLIGATIONSWas this invention developed using i) Chan/Zuckerberg BioHub facilities, ii) UCSF equipment purchased or maintained using BioHub funding, or iii) UCSF supplies obtained using BioHub funding? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX I don’t knowIf yes, was the use of these facilities, equipment, or supplies important, material, or significant to the development of this invention? FORMCHECKBOX Yes FORMCHECKBOX NoWas this invention developed using Chan/Zuckerberg BioHub funding? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX I don’t knowIf yes, was the funding used to perform activities important, material, or significant to the development of this invention? FORMCHECKBOX Yes FORMCHECKBOX NoD. INVENTORSIn this section you should list all of the contributing inventors for your invention. You should include inventors from other institutions but only inventors from UCSF need to sign this form. Under US patent law, an inventor is one who has contributed to the conception of the invention. If you are uncertain who to include as an inventor, you may review on how inventorship is determined under US patent law. If a patent application is filed, then legal inventorship may be determined by the patent attorneys based on US patent law.Name:Institutional Affiliation:Citizenship:Position:Dept:Wk. Address:Wk. Phone:Email:Should this person be our principal contact for this disclosure? Y/NName:Institutional Affiliation:Citizenship:Position:Dept:Wk. Address:Wk. Phone:Email:Should this person be our principal contact for this disclosure? Y/NName:Institutional Affiliation:Citizenship:Position:Dept:Wk. Address:Wk. Phone:Email:Should this person be our principal contact for this disclosure? Y/NPlease add additional names, if needed.FUNDING SOURCES AND THIRD PARTY RIGHTSIn this section you will provide the information necessary for us to perform our obligations to sponsors and understand whether other organizations have rights to the invention that we need to honor. In the table below, provide the full contract or grant number used for your research in development of this invention. Please include all (non-profit and for-profit) agencies, organizations and companies that provided funds, fellowships or resources that were used by any inventor in the conception or reduction to practice of this invention. If no grant funds were used, you can write “None”.Funding Source/SponsorContract or Grant NumberPrincipal Investigator/Supervisor or Fellow to whom awardedIf any inventor 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: FORMCHECKBOX Chan Zuckerberg BioHub FORMCHECKBOX HHMI (Howard Hughes Medical Institute) FORMCHECKBOX PICI (Parker Institute for Cancer Immunotherapy) FORMCHECKBOX VA (US Department of Veteran Affairs) FORMCHECKBOX CDMI (Center for Disruptive Muscuoskeletal Innovations)Does this invention use data or materials obtained from outside UCSF? FORMCHECKBOX YesIf yes, please list the name of the company or institution_____________ FORMCHECKBOX NoIf yes, was the data, material, or software obtained under either of the follow: ( ) Material Transfer Agreement - "MTA" (non-UC material) with _________________________________________________Please provide a copy of the MTA, if available( ) A subscription to the Celera Database( ) Other – please describe________________________________________________Did you transfer to any researchers outside UCSF any new materials (cell lines, vectors, plasmids, transgenic mice, etc.) related to this invention? FORMCHECKBOX Yes FORMCHECKBOX NoSIGNATURESPlease have each inventor from UCSF sign this disclosure form before submitting it. 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.Inventor's Signature:Inventor’s Name (print):Date:Inventor's Signature:Inventor’s Name (print):Date:Inventor's Signature:Inventor’s Name (print):Date:INVENTION UNDERSTOOD BY: Please include signatures of two witnesses who have read and understand this disclosure.Witness' Signature**:Witness’ Name (print):Witness’ Title/Position:Date:Witness' Signature**:Witness’ Name (print):Witness’ Title/Position:Date:** Please have PI sign if PI is not an inventor. A suitable witness is someone who has a reasonable understanding of the invention but is not an inventor and has no vested interest in the invention.Please complete, sign and send with any relevant attachments by email to: innovation@ucsf.edu For OTM:3479805080000Case No:Licensing Officer: ................
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