CASE NO.
Brought in by:
PROPRIETARY INFORMATION
UC SAN DIEGO TECHNOLOGY TRANSFER OFFICE
COPYRIGHT DISCLOSURE FORM
Please use additional sheets as necessary.
1. Title of work:
2. Description of work: (If software is part of this disclosure, please also complete Appendix A, and check here:  SOFTWARE)
3. Name(s) of Author(s):
UCSD AUTHOR(S):
Name:
UCSD Employee #:
Position:
Citizenship:
School or Division:
Dept. or ORU:
Work. Phone:
Work Address:
UCSD Mail Code:
Work. Fax:
Home Phone:
Home Email:
Home Address:
Name:
Email:
UCSD Employee #:
Position:
Citizenship:
School or Division:
Dept. or ORU:
Work. Phone:
Work Address:
UCSD Mail Code:
Work. Fax:
Home Phone:
Home Email:
Home Address:
Name:
Email:
UCSD Employee #:
Position:
Citizenship:
School or Division:
Dept. or ORU:
Work. Phone:
Home Address:
Work Address:
UCSD Mail Code:
Work. Fax:
Email:
Home Phone:
Home Email:
UCSD AUTHORS (Cont’d)
Name:
UCSD Employee #:
Position:
Citizenship:
School or Division:
Dept. or ORU:
Work. Phone:
Work Address:
UCSD Mail Code:
Work. Fax:
Email:
Home Phone:
Home Email:
Home Address:
Name:
UCSD Employee #:
Position:
Citizenship:
School or Division:
Dept. or ORU:
Work. Phone:
Work Address:
UCSD Mail Code:
Work. Fax:
Email:
Home Phone:
Home Email:
Home Address:
NON-UCSD AUTHOR(S):
Name:
Position:
Nature of Employment:
Employer:
Work Address:
Work. Phone:
Work. Fax:
Email:
Name:
Position:
Nature of Employment:
Employer:
Work Address:
Work. Phone:
Work. Fax:
Email:
4. Funding/Sponsor (include intramural and extramural funds with relevant award numbers):
5. Completion date of award project: __________________________
6. Has this work been distributed within or outside of the University?
If yes, please describe to whom and the circumstances below:
 Yes
 No
7. Does the work display a copyright notice?
If yes, reproduce it here:
 Yes
 No
8. If the work incorporates the efforts of others, please describe how and include others’ name and address.
9. List any companies that may be interested in development and distribution of this work.
10. I have received a copy of the UC Copyright Policy and the implementation guidelines and agree to abide by the terms therein.
Signature of all authors:
____________________________________________
Author signature
_____________________________________
Date
____________________________________________
Author signature
_____________________________________
Date
____________________________________________
Author signature
_____________________________________
Date
____________________________________________
Author signature
_____________________________________
Date
____________________________________________
Author signature
_____________________________________
Date
If you would like help in completing this form, please call our main number at (858) 534-5815. You may fax the completed copyright form to
our office at (858) 534-7345, with the original document submitted to:
Technology Transfer and Intellectual Property Services
University of California, San Diego
9500 Gilman Drive MC 0910
La Jolla, CA 92093-0910
Tel: 858-534-5815
Fax: 858-534-7345
http://invent.ucsd.edu
…pipeline to innovation
UNIVERSITY OF CALIFORNIA, SAN DIEGO
COPYRIGHT DISCLOSURE FORM
APPENDIX A (For Software)
1.
RECOMMENDED HARDWARE REQUIREMENTS:
Computer Manufacturer.Model:
Internal Memory Requirements:
Input/Output Devices:
Other Peripherals:
2.
RECOMMENDED OPERATING SYSTEM REQUIREMENTS:
Operating System, Version No.
Compiler:
Other Software Required:
3.
4.
DOCUMENTATION (For each item identify type of document: [A] HARD COPY; [B] ON-LINE; [C] BOTH; [D] NONE)
User’s Guide
Control Information
Sample Problem Input
Installation Guide
Data Libraries
Sample Problem Output
Technical Documentation
Illustrations
MEDIA:
Media Type:
Media contains:
5.
 Source Code
 Object Code
COPYRIGHT QUESTIONS:
Please answer Yes or No to the following questions. If any answers are yes, attach an additional sheet with explanations.
Was any of the code written by someone who is not listed as a author (e.g., student performing under direction of
faculty)?
Was any of the code used subject to a prior copyright or patent?
Has the softeware been discussed and/or any of the code published in a thesis or article?
Does the software include creator acknowledgment?
Does the software include a copyright notice?
Does the software include a sponsorship acknowledgment?
6.
MARKETING QUESTIONS:
Describe the audience for whom the item was designed:
Are there similar items currently in the marketplace?