INVENTION REPORT AND RECORD
Information herein is submitted for purposes of seeking legal advice concerning
patentability. Such information is subject to legal and other review and confirmation.
A.
TITLE of the Invention: (should be brief and descriptive)
B.
Potential INVENTOR(s): (inventorship subject to review)
Full name:
Country of Citizenship:
Home Address:
City, State, Zip:
Telephone:
E-mail Address:
Employer:
Full name:
Country of Citizenship:
Home Address:
City, State, Zip:
Telephone:
E-mail Address:
Employer:
Full name:
Country of Citizenship:
Home Address:
City, State, Zip:
Telephone:
E-mail Address:
Employer:
Full name:
Country of Citizenship:
Home Address:
City, State, Zip:
Telephone:
E-mail Address:
Employer:
Full name:
Country of Citizenship:
Home Address:
City, State, Zip:
Telephone:
E-mail Address:
Employer:
Full name:
Country of Citizenship:
Home Address:
City, State, Zip:
Telephone:
E-mail Address:
Employer:
C.
State what the INVENTION is: (also describe how you envision the invention could be
used; at a level of descriptiveness similar to the abstract of a journal publication)
D.
Has a MANUSCRIPT been prepared for submission to a research journal?
If yes, please attach the manuscript, and related figures, tables, sequences, etc., including
materials and methods sections.
If no, please provide a full description of the invention, including as much detail as
possible. Please include figures, starting materials, methods of preparation, operative and
preferred ranges of any named parameters, and any other forseeable uses of the invention.
For example, a grant proposal, grant progress report, etc., may be appropriate.
E.
What are the BENEFITS to be realized through the use of this invention? For example:
cost, quality and performance improvements, new features and products, new
treatments, etc.
F.
Are you aware of any ALTERNATIVES that exist for accomplishing substantially the
same result of this invention?
List the CLOSEST technologies or references you are aware of:
G.
What are the technical BENEFITS obtained, PROBLEMS solved, and ADVANTAGES
your invention provides over the alternatives identified above?
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H.
How does your invention DIFFER from the closest technologies or references
described above?
I.
Other possible commercial APPLICATIONS for the invention include:
J.
Federal Grant/Contract or Subcontract Funding:
Was the invention conceived or first actually reduced to practice in the performance of
work funded, in whole or in part, by any federal grant(s), contract(s) or subcontract(s)? If yes, list
below.
Will any federal sponsoring entity be acknowledged if information related to this
invention is published or disseminated to the scientific community? If yes, list below.
K.
Publication, Public Disclosure & Other Activities:
Date this invention was or is expected to be disclosed outside of your organization:
Described in any publication(s) (including abstracts)?
Manuscript submitted for publication? If yes, has it been accepted?
Poster session, presentation, or lecture?
Appeared online (including conferences and abstracts)?
Grant application submitted for review?
Date this invention was used or is committed to be used in production:
Was the invention or any derivative product sold, offered for sale, or used in public?
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Were any materials (biological or otherwise), documents, information or software related
to the invention provided or disclosed to any third party (including academia, industry or
government)?
If yes, was there a confidentiality agreement in place?
If yes, please note the date and circumstances of the disclosure:
Are any of the above disclosures or activities contemplated in the near future?
If yes to any of the above, please provide additional details:
L.
Is the invention related to any third party agreements not identified elsewhere on this
form?
Materials obtained from a third party, e.g., under a Material Transfer Agreement (MTA)?
Sponsored Research Agreements (SRAs)?
Equipment from a third party?
Other?
If yes, to any of the above, please provide details:
M.
Inventor Affiliations:
At the time of making an inventive contribution, were any potential inventors employees,
officers, or students of an entity other than this organization?
At the time of the inventive contribution, were any inventors employed by more than one
entity concurrently (i.e., shared salaries)?
N.
Conception and Experimentation
When did you first think of this invention:
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What records do you have to substantiate this conception date (Identify records that
establish dates of conception and reduction to practice, including the records’ present location
and the identity of the person who prepared them. Attach copies if possible. Note additional
supporting evidence. If the invention or a significant aspect of the invention is not supported by
written records, briefly describe how the date of invention can be established and identify the
earliest written record):
To whom did you first disclose this invention:
On what date did you make such disclosure:
When did you first do any actual experimental work toward carrying out the invention:
Upon what date were you satisfied that you had solved the problem toward which your
invention was directed:
Who has observed the progress of your experimental work:
O.
Is research continuing on this invention (if yes, please describe research plans).
P.
Are you aware of third parties that may be interested in this invention?
Q.
How would you determine whether a third party was making, using, or selling the
invention without authorization?
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