OFFICE USE ONLY
Tech ID
_________________________
Submit completed forms to:
U.Va. Licensing & Ventures Group
250 W. Main St., Suite 300
Charlottesville, VA 22902
(434) 924-2175 | LVG@virginia.edu
CONFIDENTIAL INFORMATION
University of Virginia
Research Reagent
Disclosure Form
The purpose of this form is to facilitate the prompt disclosure by University of Virginia (U.Va.) faculty and staff of any laboratory research reagents (e.g.,
monoclonal and polyclonal antibodies, immortalized cell lines, mouse strains, etc.) that result from University research pursuant to the U.Va. Patent Policy
effective June 23, 1993. Please review the attached instructions and guidelines.
Please note: This form is to be used for laboratory research reagents only. If your reagent may have broader applications (e.g., as a diagnostic or
therapeutic, etc.), please instead complete the Intellectual Property Disclosure Form available at http://innovation.virginia.edu/disclose.
1. Title of Research Reagent
3. Inventors*
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U.Va. Contributor Legal Name
Primary Department at U.Va.
% Contribution
(Column must
total 100)
Department
%
Department
%
Department
%
Department
%
Department
%
Employer/Institution
% Contribution
Institution
%
Institution
%
Institution
%
Institution
%
2. Description: Please provide a brief summary of the
reagent and its uses, referring to the instructions on
Page 4.
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Non-U.Va. Contributor Legal Name
*Please list all persons who are believed to have made significant contributions to the
generation of the research reagent, including U.Va. faculty and staff as well as inventors
from other institutions, in the appropriate fields above.
4. Was this intellectual property developed with the use of any research grant/contract funds?
Grant/Contract No.
Sponsor
< Click to select YES or NO >
Principal Investigator
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5. Please list any material transfer agreements (incoming and/or outgoing) or other agreements (confidentiality agreements, etc. — other than those
listed in Section 4 above) that are relevant to this research reagent.
Institution/Company
Date
Material
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6. Publications: Please include reference and URL if available.
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7. Please list any potential licensees or commercial partners.
Please provide as much detail as possible, including any professional contacts and contact information.
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8. Type of Research Reagent: < SELECT REAGENT TYPE >
If monoclonal antibody, skip to Section 9.
If polyclonal antibody, skip to Section 10.
If mouse strain, skip to Section 11.
If other (plasmids, recombinant proteins, cell lines, etc.), skip to Section 12.
9. For Monoclonal Antibodies Only
A. Immunogen Information
i. Protein name(s): Enter text.
ii. Species: Enter text.
iii. Accession number and database (if
known): Enter text.
iv. Type of immunogen: < SELECT >
If “Other,” describe type: Enter text.
v. Is the immunogen full length or partial?
< SELECT >
If “Partial,” specify amino acids: Enter
text.
vi. The immunogen is: < SELECT >
If “Mutant/post-translationally
modified,” describe: Enter text.
vii. Fusion partner (e.g., FLAG, KLH, GST,
6-His, etc.): Enter text.
B. Hybridoma Information
C. Antigen Information
i. Epitope (if known): Enter text.
ii. Species cross-reactivity: Enter text.
iii. Enter concentrations for any tested
applications:
WB: Enter text.
ELISA: Enter text.
IF(ICC): Enter text.
IHC: Enter text.
IP: Enter text.
Other (specify application and
concentration): Enter text.
10. For Polyclonal Antibodies Only
A.
B.
C.
D.
E.
F.
G.
H.
D. The Lymphocyte Culture Center
i. Species immunized (lymphoid cells
derived from): Enter text.
ii. Myeloma parent: Enter text.
iii. Clone number: Enter text.
iv. Produced as …
Acites?: < SELECT >
Culture supernatant?: < SELECT >
v. Immunoglobulin isotype: Enter text.
vi. Antibody purification method: Enter text.
The U.Va. Licensing & Ventures Group (LVG)
maintains a permanent collection of monoclonal
antibody hybridomas at the U.Va. Lymphocyte
Culture Center (LCC). If your material is not on
deposit there, please make the deposit with
instructions to the LCC indicating that the
material is for the U.Va. LVG collection.
Depositing your material into this collection will
allow LVG to distribute your hybridoma after
licensing, relieving your lab of the burden of
packaging and shipping responsibilities. Our
collection will also serve as a back-up source of
your hybridoma. This service applies to
monoclonal antibodies only. You will not be
billed for this service.
If already deposited, date of deposit:
MM/DD/YYYY
11. For Mouse Strains Only
Protein name(s): Enter text.
Species: Enter text.
Accession number (specify database, if known): Enter text.
Type of immunogen: < SELECT >
If “Other,” describe type: Enter text.
Is the immunogen full length or partial? < SELECT >
If “Partial,” specify amino acids: Enter text.
The immunogen is: < SELECT >
If “Mutant/post-translationally modified, describe: Enter text.
Fusion partner (e.g., FLAG, KLH, GST, 6-His, etc.): Enter text.
Antibody information
i. Species immunized: Enter text.
ii. Immunoglobulin isotype: Enter text.
iii. Epitope (if known): Enter text.
iv. Species cross-reactivity:
Enter text.
v. Enter concentrations for any tested applications:
WB: Enter text.
ELISA: Enter text.
IF(ICC): Enter text.
IHC: Enter text.
IP: Enter text.
Other (specify application and concentration): Enter text.
vi. Type of material available: < SELECT >
If “Purified antibody,” describe purification method: Enter text.
vii. Amount available (ml): Enter text.
A. For Targeted Mutation Strain Generation Only
i. Founder background: Enter text.
ii. Donor background: Enter text.
iii. Targeted gene name: Enter text.
iv. Strain nomenclature (if known, as described by the
International Committee on Standardized Genetic
Nomenclature for Mice): Enter text.
v. Description of strain generation: Enter text.
B. For Transgenic Strain Generation Only
i. Genetic background: Enter text.
ii. Genetic insert description: Enter text.
iii. Strain nomenclature (if known, as described by the
International Committee on Standardized Genetic
Nomenclature for Mice): Enter text.
iv. Description of strain generation: Enter text.
C. Strain Description
What are the strain phenotypes and uses? Enter text.
12. For All Other Research Reagents (Plasmids, Recombinant Proteins, Cell Lines, etc.)
Additional Information
Please include any additional information about your reagent here:
Click here to enter text.
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Revised 02/05/2013
UNIVERSITY OF VIRGINIA CONTRIBUTORS – COMPLETE THIS SECTION
I (we) hereby certify that all of the information set forth in this disclosure is true and complete to the best of my (our) knowledge. I (we) have
also specifically reviewed and agree with the percent contribution allocations set forth in Section 3 above.
Pursuant to the U.Va. Patent Policy, I (we) hereby confirm the prior assignment of all of my (our) right, title and interest to this intellectual
property to the University of Virginia and agree to execute all documents as requested, to assign to the University of Virginia all of my (our)
rights to any patent application filed on this intellectual property, and to cooperate with the University of Virginia and the University of
Virginia Patent Foundation d/b/a the University of Virginia Licensing & Ventures Group (LVG) in the protection and commercialization of this
intellectual property. Further, pursuant to the U.Va. Copyright Policy, I hereby acknowledge the University’s ownership of any copyrights in
the intellectual property described and disclosed below. The University of Virginia will share any royalty income derived from the intellectual
property with the inventor(s) according to its published policies.
Signature
Date
Signature
Date
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Phone
E-mail Address
Phone
E-mail Address
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Home Address (Street, City, State ZIP)
Home Address (Street, City, State ZIP)
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Country of Citizenship
Country of Citizenship
Signature
Date
Signature
Date
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Phone
E-mail Address
Phone
E-mail Address
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Home Address (Street, City, State ZIP)
Home Address (Street, City, State ZIP)
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Country of Citizenship
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OFFICE USE ONLY
Signature
Date
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Phone
E-mail Address
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PURSUANT TO THE MEMORANDUM OF UNDERSTANDING BETWEEN THE RECTOR
AND VISITORS OF THE UNIVERSITY OF VIRGINIA (U.VA.) AND THE UNIVERSITY
OF VIRGINIA LICENSING & VENTURES GROUP (U.VA. LVG) EFFECTIVE JULY 1,
2011, U.VA. HEREBY ASSIGNS ALL OF ITS RIGHT, TITLE, AND INTEREST IN THIS
INTELLECTUAL PROPERTY TO U.VA. LVG.
Home Address (Street, City, State ZIP)
______________________________________________
EXECUTIVE DIRECTOR, U.VA. INNOVATION
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Country of Citizenship
NON-U.VA. CONTRIBUTORS – COMPLETE THIS SECTION
I (we) hereby certify that all of the information set forth in this disclosure is true and complete to the best of my (our) knowledge. I (we) have
also specifically reviewed and agree with the percent contribution allocations set forth in Section 3 above.
Please note that you may have an obligation to disclose and assign your rights in this intellectual property to your employer/institution. U.Va.
LVG may independently contact your employer/institution to ensure appropriate disposition of all intellectual property disclosed on this form.
Signature
Date
Signature
Date
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Phone
E-mail Address
Phone
E-mail Address
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Home Address (Street, City, State ZIP)
Home Address (Street, City, State ZIP)
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Country of Citizenship
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(For disclosures with additional contributors, a supplemental signature page is provided at the end of this document.)
Page 3 of 5
Revised 02/05/2013
Instructions
I. The University of Virginia Licensing & Ventures Group (LVG) reviews all U.Va. intellectual property and research
reagent disclosures as they are received from the U.Va. community. Where appropriate, LVG endeavors to
license U.Va. intellectual property and research reagents to industry for further development and
commercialization. Any royalties derived from any such license are shared with the inventor(s) and their labs,
departments and schools according to the Innovation Revenue and Equity Distribution Formulas. This form
notifies LVG of your research reagent and any relevant sponsorship, related agreements and publication history.
II. The following instructions apply to the correspondingly numbered sections in the form:
1. Use a brief descriptive title to aid in identifying the research reagent (i.e., “Protein X monoclonal
antibody,” “Protein Y polyclonal antibody”).
2. Provide a summary describing the generation and uses of your reagent. Note any purchased materials
that are incorporated into your reagent, including genes for fluorescent proteins, proprietary reporter
systems and commercial plasmids.
3. Include the names of any potential co-inventors at U.Va. (top) and other institutions/organizations
(bottom). A co-inventor is an individual who has conceived or contributed an essential element of the
invention, either independently or jointly with others, during the evolution of the technology concept or
reduction to practice. Include the percent contribution to the invention for each inventor as mutually
agreed upon by all of the inventors. Absent agreement by all inventors to a percent contribution split that
totals 100%, the LVG default position is to assume equal percent contributions for each inventor.
4. List all sources of funding that relate to the creation/development of the intellectual property by providing
the applicable contract or grant number(s), the funding agency and the principal investigator on the
project(s), including departmental, governmental, industrial and/or foundation support (e.g., NIH,
departmental, Coulter Foundation, other external sponsors, etc.).
5. List all Material Transfer Agreements (MTAs) and other agreements wherein material and/or terms relate
to the research reagent. Include materials received from non-U.Va. laboratories that are incorporated into
your reagent.
6. List any publications that describe the generation, use or characterization of your research reagent.
Include links/URLs if available.
7. A list of companies that may be interested in the invention will assist LVG in identifying potential licensees
for the technology. Please include names and addresses of specific contacts if known.
Page 4 of 5
Revised 02/05/2013
Supplemental Signature Page
UNIVERSITY OF VIRGINIA CONTRIBUTORS – COMPLETE THIS SECTION
I (we) hereby certify that all of the information set forth in this disclosure is true and complete to the best of my (our) knowledge. I (we) have
also specifically reviewed and agree with the percent contribution allocations set forth in Section 3 above.
Pursuant to the U.Va. Patent Policy, I (we) hereby confirm the prior assignment of all of my (our) right, title and interest to this intellectual
property to the University of Virginia and agree to execute all documents as requested, to assign to the University of Virginia all of my (our)
rights to any patent application filed on this intellectual property, and to cooperate with the University of Virginia and the University of
Virginia Patent Foundation d/b/a the University of Virginia Licensing & Ventures Group (LVG) in the protection and commercialization of this
intellectual property. Further, pursuant to the U.Va. Copyright Policy, I hereby acknowledge the University’s ownership of any copyrights in
the intellectual property described and disclosed below. The University of Virginia will share any royalty income derived from the intellectual
property with the inventor(s) according to its published policies.
Enter legal name here Signature
Date
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Date
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Phone
E-mail Address
Phone
E-mail Address
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Home Address (Street, City, State ZIP)
Home Address (Street, City, State ZIP)
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Country of Citizenship
Country of Citizenship
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Date
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Date
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Phone
E-mail Address
Phone
E-mail Address
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Home Address (Street, City, State ZIP)
Home Address (Street, City, State ZIP)
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Country of Citizenship
Country of Citizenship
OFFICE USE ONLY
Enter legal name here Signature
Date
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Phone
E-mail Address
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PURSUANT TO THE MEMORANDUM OF UNDERSTANDING BETWEEN THE RECTOR
AND VISITORS OF THE UNIVERSITY OF VIRGINIA (U.VA.) AND THE UNIVERSITY
OF VIRGINIA LICENSING & VENTURES GROUP (U.VA. LVG) EFFECTIVE JULY 1,
2011, U.VA. HEREBY ASSIGNS ALL OF ITS RIGHT, TITLE, AND INTEREST IN THIS
INTELLECTUAL PROPERTY TO U.VA. LVG.
Home Address (Street, City, State ZIP)
______________________________________________
EXECUTIVE DIRECTOR, U.VA. INNOVATION
Click here to enter text.
Country of Citizenship
NON-U.VA. CONTRIBUTORS – COMPLETE THIS SECTION
I (we) hereby certify that all of the information set forth in this disclosure is true and complete to the best of my (our) knowledge. I (we) have
also specifically reviewed and agree with the percent contribution allocations set forth in Section 3 above.
Please note that you may have an obligation to disclose and assign your rights in this intellectual property to your employer/institution. U.Va.
LVG may independently contact your employer/institution to ensure appropriate disposition of all intellectual property disclosed on this form.
Signature
Date
Signature
Date
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Phone
E-mail Address
Phone
E-mail Address
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Home Address (Street, City, State ZIP)
Home Address (Street, City, State ZIP)
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Country of Citizenship
Country of Citizenship
(For disclosures with additional contributors, copy this page or contact the U.Va. Licensing & Ventures Group for additional pages.)
Page 5 of 5
Revised 02/05/2013