Inventor(s)



INTELLECTUAL PROPERTY DISCLOSURE FORMFOR RECORD AND EVALUATIONThe purpose of this form is to record and provide information for the evaluation of research results which are of potential commercial value. It is important that the University has an idea of the potential commercial value of the technology, the target markets and the competitors.Please use additional sheets when necessary, as some questions will require more space than is provided. Please complete this form as fully as possible; for help please contact a member of the Technology Transfer Office on (632) 524 – 2011 loc 340 or 516 – 4837. Inventor(s)Please complete details for each inventor, continue on a separate page if necessary.Inventor No. 1 Name Degree or Employment Status Work Address Home Address Email Address Contact Number/s Nationality Inventor No. 2Name Degree or Employment Status Work Address Home Address Email Address Contact Number/s Nationality Inventor No. 3 Name Degree or Employment Status Work Address Home Address Email Address Contact Number/s Nationality Inventor No. 4 Name Degree or Employment Status Work Address Home Address Email Address Contact Number/s Nationality Title of Invention Please write a short descriptive title that we can use for your invention. (Title should be as short as specific as possible clearly and concisely stating the technical designation of the invention. Exclude fancy names that do not define the invention) Class of Invention. What is your invention (please select as appropriate)Material/ compoundProcess/ methodSoftwareDevice/ prototypePotential drug targetDiagnosticTeaching/ learning materialServiceOthers (please describe) When and where the invention was first described in writing? Description of Invention Please include a description of the invention, writing as much as needed and continuing on as many pages as necessary. Please also attach relevant drawings, chemical structures and data. What is the purpose of the invention? (what is the use or purpose of your device or apparatus or process)What problem does it solve? (Statement of the problem) In order to identify the novel elements of your invention, please cite your nearest patent and/ or non – patent prior art. What are the key novel elements of the invention? A comparative table stating the following would be highly appreciated in your disclosure. Feel free to expand the table. Your invention Document 1 (please state number & title of document) Document 2(please state number & title of document) Document 3 (please state number & title of document) Enumerate the components of the device (feel free to add lines) Enumerate the step by step method or process For chemical field, enumerate the composition of your invention (if applicable) For chemical field, enumerate the formulation of your product What is the problem being solved by your inventionConsidering your tabulation in 3.3, what are the advantages of your invention over the prior art you have identified? What are the advantages of the prior art. (You may add lines)Your invention’s advantages Prior art advantagesConsidering your tabulation in 3.3, what are the disadvantages of this invention compared to existing work? (You may add lines)Prior art 1 DisadvantagePrior art 2 DisadvantagePrior art 3 DisadvantagePlease describe why would you consider your invention as inventive? What developmental stage is the invention at? Concept only Prototype (alpha stage) Prototype (beta stage) Laboratory tested Others What other implementations/ variations/ use of this invention would be possible? What would the final “product” be used for? Are there any other uses for the invention? DisclosureIt is important for the University to know if your invention has been made public, as this may affect the strength of any patent application and the commercial potential. 4.1 Written disclosures. Please list, with dates, any past and planned written publications presenting the invention or data in this invention (journal papers/abstracts/posters/internet/other).Past written disclosures Planned written disclosures4.2 Oral Disclosures. Please list, with dates, any past and planned oral disclosures of the invention (e.g. presentations at internal or external seminars, disclosure to a company under a confidentiality agreement etc) and any demonstrations of the invention.Past oral disclosures Planned oral disclosures4.2 Future Work. Please briefly outline any future research or development work that is planned for this invention. 4.2 Prior Art. Please enumerate your relevant references (patent and non-patent literature like journals and the like). Use either APA or IEEE formatPlease also list your own publications (including articles, abstracts, posters, webpage) which are in the field and which are not listed above. Research FundingThe University must know whether other organisations may have rights to your invention or to any technology that you have developed, so that we can reach agreements with them over our respective protection and exploitation rights.5.1 Period of research relevant to the creation of the intellectual property Starting DateEnding Date5.2 Was the research leading to this intellectual property during that period or any part of it, funded in whole or in part by a third party? NoYes (please proceed to question 5.3)5.3 please name the third party and the grant/s or funding receivedFunding SourceGrant/ contract PeriodProject Code5.4 If applicable, please list any third party owned materials and/ or know how that this invention uses, including the name of the third party/5.4 Is this invention linked to the subject matter of other research agreements, MTAs, consultancies or other contracts (not listed above) that currently exist, or have expired, or are being negotiated? Please provide details if YES. NoYes Inventors’ contributionsPlease give a brief description of each of the roles of those named in this invention disclosure: Your disclosure of your contribution should be very specific as it would establish your ownership or contribution to the work. Amount of contribution are not equal, thus, your specific tasks/ actions are expected to be enumerated here. You are free to expand this table to explain your contribution. SampleInventor’s Name Contribution in developing the invention ACBSoftware development, component testingCSGPrototype testing and documentation RNTIntegration and documentation ADYadviserNot acceptable statement of contribution as they are too generic. What did you actually do? Inventor’s Name Contribution in developing the invention SignaturesEach person listed as an inventor should sign and date in the space below. By signing this document, you verify that the information given above is correct to the best of your knowledge and belief NameSignatureDateSigned by a representative of the Innovation and Technology Support Office:Name:Date:Thank you for taking the time to complete this form. Please return it to the Innovation and Technology Support Office, Adamson University, Manila. Please also email a copy (without signatures) itso@adamson.edu.ph . If you have any queries, please call (632) 524 - 2011 loc 340 or 516-4837. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download