FLORIDA INTERNATIONAL UNIVERSITY



FLORIDA INTERNATIONAL UNIVERSITY

CONFIDENTIAL

INTELLECTUAL PROPERTY DISCLOSURE FORM

This Confidential Intellectual Property Disclosure Form is to be filed at Florida International University (FIU) when intellectual property has been clearly conceptualized. Inventions can include any discovery, new and useful process, product, apparatus, composition of matter, living organism or improvement to (or new use for) things that already exist.

The purpose of this disclosure form is to notify the Office of Technology Management and Commercialization (OTMC) of the potential invention and any relevant sponsorship and publication history. Please note that premature publications, presentations, or other forms of public disclosure can negatively impact subsequent efforts to patent or commercialize an invention.

The person completing this form should provide a copy of the completed form to all other persons identified as contributors on the signature page.

If the technology being disclosed is software, complete only sections I, III, V, VI, VII, VIII (if applicable only, see section III below) and IX.

I. TECHNOLOGY TITLE      

II. TECHNOLOGY DESCRIPTION

Provide a brief description of the technology with a sufficient amount of detail that will assist in understanding the technical merits, commercial usefulness and practical applications of the work. Sketches, drawings, photos, reports and manuscripts are helpful. (Use additional sheets and attach descriptive materials to expand answers to questions.)      

What are the immediate and/or future applications/purposes of the technology?      

Why is the technology better - more advantageous - than present technology? What are its novel and unusual features? What problem(s) does it solve?      

Is work on the technology continuing? Are there limitations to be overcome or other tasks to be done prior to practical application? Are there any test data?      

Have products, prototypes, apparatus or compositions actually been made or tested?      

III. SOFTWARE DISCLOSURE (THIS SECTION TO BE FILLED OUT FOR SOFTWARE ONLY, IF APPLICABLE)

When was the software code first created?      

If the technology being disclosed is software, please attach a CD or DVD containing a copy of the entire source code and a CD or DVD containing an executable version of the software. These will enable OTMC to maintain an accurate record of the software and to identify any unauthorized copying of the software or any part of it.

List all third party code embedded in or accessed by the disclosed software when such software is run. This list must include, without limitation, all open source code, free executable code, public domain code, library code, and all other executable or source code not written by any of the inventors listed in this Disclosure form, whether such code is directly embedded in the software or accessed by the software when it is executed.

Name of Third Party Webpage to Download Code Web Page Location of

Code Third Party License

                 

                 

Add additional pages as necessary. Additional pages are added: YES NO

Do you request that the software be made available pursuant to an open source license?

YES NO This means that the software will be made publicly available at no charge and no royalties or fees will be collected for its use. OTMC will support a request for open source license subject to any third party rights, as listed above, and as retained by any external sponsor whose funding was used to develop the software.

If open source license is requested, please select one of the following license forms from the Open Source Initiative at . OTMC recommends the following licenses:

BSD: the University retains copyright ownership, but makes the software openly available to the public without the requirement that redistribution of the software include the source code. This is the least restrictive open source license. If the University approves the open source distribution, the BSD license template should be included conspicuously within the released software copy and at the side where the software is downloaded.

GNU Public License (GPL) or GNU Library or “Lesser” General Public License (LGPL): the University retains copyright ownership, but makes the software openly available to the public with the requirement that redistribution of the software, in whole or in part (or any modification of or addition to the software) include the source code. The applicable license contains instructions on how to release the software in accordance with the license terms.

If a license form other than BSD, GPL or LGPL is requested, OTMC will confer with you about that license form. I hereby request the following alternate license form from the Open Source Initiative at or an open source license that includes the following terms:      

Do you believe that the software has commercial value that may be licensed? YES NO If yes, then please complete section VIII. ECONOMIC/MARKET IMPACT OR INFORMATION.

IV. HISTORY OF INVENTION/DISCOVERY (Provide dates, locations and any necessary comments.)

When was the idea for the invention first conceived?      /     /     . Please describe:      

When was the first sketch or drawing developed?      /     /     . Please describe:      

When was the first written description developed?      /     /     . Please describe:      

Which FIU college(s), center(s), or department(s) was most instrumental in supporting development of this technology?     

V. PUBLICATIONS, PUBLIC USE AND SALE (Patent protection depends on accurate answers to the following questions. Use additional sheet(s), if necessary.)

Has technology (code, in the case of software) been disclosed (e.g. in an abstract, paper, talk, news story, discussion, research/research results report, presentation, thesis/dissertation)? YES NO

Type of disclosure (Include a copy with this form):      

Disclosure Date (MM/DD/YYYY):      

Is a publication or other public disclosure (e.g. abstract, paper, talk, news story, discussion, research/research results report, presentation, thesis/dissertation) planned within the next 12 months? YES NO

Date of this planned disclosure (MM/DD/YYYY):      

Type of disclosure planned (Include a copy or description of what has been disclosed with this form):      

Has there been any public use or sale of products embodying the technology? YES NO

Describe, giving dates (MM/DD/YYYY):      

VI. PRIOR ART SEARCH

A prior art (i.e. related published patents) search can be done using the U.S. Patent and Trademark Offices databases. To further assist you in completing the following questions, you may conduct a prior art search by visiting and .

Are you aware of related developments by others? If yes, please give citations.      

Cite any close or related patents of which you are aware:      

VII. SPONSORSHIP

If the invention was created under research funded by a sponsor (e.g. a government agency, nonprofit, or commercial entity), the university may have obligations to report the invention or convey certain rights to the sponsor. Please carefully consider all sources of funding used in research leading to the invention, including funding used for salaries of all contributors/inventors, supplies, equipment and services, and provide the information requested below.

Funding Agency or Sponsor:      

Award or Contract No.:      

FIU Project ID No.:      

Federally/U.S. Government Sponsored? Yes No

Has the technology been disclosed to industry or government representatives? (If yes, please provide details including names of companies/agencies and the representatives.)      

VIII. ECONOMIC/MARKET IMPACT OR INFORMATION

Briefly describe the technical impact this technology is likely to have on the field of endeavor (i.e., marginal improvement, significant change, creates new field, etc.) and explain why.      

Describe commercial applications of the technology.      

Explain briefly the degree of technical development of this technology (i.e., prototype, complete product/process, ready for commercial testing/marketing, etc.).      

Give an estimate of the nature and amount of work which still remains to be done before a commercial venture/product is obtained.      

What do you see as the greatest impediment to the adoption of your invention?      

If technology of this type were pursued, do you consider it worthwhile to spend upwards of $10,000 to obtain a U.S. Patent? YES NO Please explain:      

List the names and telephone numbers of persons with technical or economic knowledge in the field of the technology, who could be asked (under confidentiality agreements) to review, assess or evaluate the technical and commercial potential of this technology. Please list at least two FIU faculty or staff members as part of this group.      

List any companies of which you are aware that may be interested in this technology (contact names and telephone numbers are useful).      

Provide any additional pertinent and useful information (not covered elsewhere in this form) which may provide guidance regarding this technology and its optimal utilization.      

IX. IDENTIFICATION OF CONTRIBUTOR(S)

A. List the individuals, those who are believed to have contributed to the conception or reduction-to-practice of the invention, including any non-University personnel. If there are more than four contributors, complete and attach an additional contributor identification page. (Please print clearly and sign where indicated):

1. Name:      

Title:      

Dept.:      

Telephone No.:      

Email:      

Work Address:      

Permanent Address:      

Country of Citizenship:      

Nature of Contribution:      

Signature: _____________________________

Date:      

2. Name:      

Title:      

Dept.:      

Telephone No.:      

Email:      

Work Address:      

Permanent Address:      

Country of Citizenship:      

Nature of Contribution:      

Signature: _____________________________

Date:      

3. Name:      

Title:      

Dept.:      

Telephone No.:      

Email:      

Work Address:      

Permanent Address:      

Country of Citizenship:      

Nature of Contribution:      

Signature: _____________________________

Date:      

4. Name:      

Title:      

Dept.:      

Telephone No.:      

Email:      

Work Address:      

Permanent Address:      

Country of Citizenship:      

Nature of Contribution:      

Signature: _____________________________

Date:      

Note: The foregoing list should include names of persons who may qualify as legal inventors. Inventorship is a matter of law and is determined with assistance of the attorney of record.

B. Identify the FIU faculty or staff member with whom the Office of Technology Management and Commercialization should communicate regarding this technology.

Name:      

Title:      

Dept.:      

Telephone No.:      

Email:      

Work address:      

| |

|Department Chairperson Authorization |

| |

|I have reviewed and authorize the submission of the disclosure form for the invention (technology title)     . |

| |

|Name of Chairperson:       |

| |

|Name of Department:       |

| |

|Chairperson Signature: |

| |

|Date: |

| |

|Dean of College (or Designee) Authorization |

| |

|I have reviewed and authorize the submission of the disclosure form for the invention (technology title)     . |

| |

|Name of Dean:       |

| |

|If Designee, name of Designee:       |

| |

|Name of College: |

| |

|Dean/Designee Signature: |

| |

|Date: |

A completed hardcopy of this Intellectual Property Disclosure Form with original signature pages is to be submitted to:

Office of Technology Management and Commercialization

Division of Research

Florida International University

Modesto Maidique Campus, MARC 440

Miami, FL 33191

Telephone: (305) 348-0008 ● Fax: (305) 348-0081

................
................

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

Google Online Preview   Download