BIOLOGICAL MATERIALS DISCLOSURE FORM
INSTRUCTIONS

Use this form to provide detailed information regarding your reagent.

If you think your reagent may have broader applications than as a research reagent, such as for a
diagnostic or therapeutic, please fill out our standard invention disclosure form available online at
http://www.k-state.edu/tech.transfer/forms/forms.htm. If you are unsure or have any questions about
your reagent, please contact us at tech.transfer@ksu.edu or 785-532-5720.

Please complete the appropriate section of the type of reagent you are disclosing:
o
o
o
o
For monoclonal antibody, complete page 2.
For polyclonal antibody, complete page 3.
For mouse strains, complete page 4.
For all other research reagents (including plasmids, recombinant protein, cell lines, etc.),
complete page 5.

Please note that KSU Research Foundation is now collecting Wildcat ID numbers rather than social
security numbers for security and privacy reasons.

All K-State contributor(s) listed on page 6 of this form MUST sign and date on page 8.

Non-K-State contributor(s) are NOT required to sign this form, but their contact information must be
provided on page 7.

Return the completed disclosure form to:
KSU Research Foundation
2005 Research Park Circle, Suite 105
Manhattan, KS 66502-5020
Revised Sept. 2011
KSU Research Foundation - 2005 Research Park Circle, Suite 105 – Manhattan, KS 66502-5020
Phone: 785-532-5720 Fax: 785-532-3920 Web: http://k-state.edu/tech.transfer
KSURF USE ONLY
DISC. NO. ___________
BIOLOGICAL MATERIALS DISCLOSURE FORM
FOR ALL RESEARCH REAGENTS
1. Reagent Title (E.g., “Protein X monoclonal antibody”, “Protein Y polyclonal antibody”):
2. Publications (Any publications that describe your research reagent, attach additional list if
necessary.):
3. Funding Sources/Contracts that Contributed to the Research Related to the Invention:
(As funding often carries obligations to a sponsor, be sure to include all agencies, organizations, or
companies that provided any funding to any contributor for the research that led to the conception or
first actual reduction to practice of the invention.)
THIS SECTION MUST BE COMPLETED, USE”N/A” IF NOT APPLICABLE
Name of Sponsor
Grant Number
Contact Information
4. Potential Licensees (If you know of a specific company that is or may be interested in your reagent,
please provide names of companies, include contact name, if known.):
Company Name
Contact Name
Phone and Email Address
5. Materials/Facilities Used: Were any materials used to create this reagent obtained from a third party
or was any portion of the research that led to this invention conducted in another institution, a
company or otherwise outside of Kansas State University:
Yes
No
If “Yes”, please specify:
a. Agreement type (e.g., Material Transfer Agreement, Collaborative Agreement, Research
Agreement etc.):
b. Company/Institution name:
6. Additional information that you would like to let us know about your reagent :
Return Completed Form to:
KSU Research Foundation - 2005 Research Park Circle, Suite 105 – Manhattan, KS 66502-5020
Phone: 785-532-5720 Fax: 785-532-3920 Web: http://k-state.edu/tech.transfer
Page | 2
REAGENT INFORMATION AND DESCRIPTION
Complete the appropriate section for the type of reagent you are disclosing (e.g., monoclonal antibody,
polyclonal, mouse strain or other).
For Monoclonal Antibodies Only
Immunogen Information:
1. Protein Name(s):
2. Species:
3. Accession Number (specify database, if known):
4. Type of Immunogen (check one):
Recombinant Protein
Peptide
Purified Native Protein
Other - describe:
5. The immunogen is (check one):
Full length
Partial - specify amino acids:
6. The immunogen is (check one):
WT
Mutant/post-translationally modified - describe:
7. Fusion Partner (e.g., FLAG, KLH, GST, 6-His, etc.):
Hybridoma Information:
1. Species Immunized (lymphoid cells derived from):
2. Myeloma Parent:
3. Clone Number:
4. Produced as:
Acites
Culture supernatant
5. Immunoglobulin Isotype:
6. Antibody Purification Method:
Antigen Information:
1. Epitope (if known):
2. Species Cross-Reactivity:
3. Tested Applications:
WB
ELISA
IF (ICC)
IHC
IP
Other - please specify:
Return Completed Form to:
KSU Research Foundation - 2005 Research Park Circle, Suite 105 – Manhattan, KS 66502-5020
Phone: 785-532-5720 Fax: 785-532-3920 Web: http://k-state.edu/tech.transfer
Page | 3
For Polyclonal Antibodies Only
1. Protein Name(s):
2. Species:
3. Accession Number (specify database, if known):
4. Type of Immunogen (check one):
Recombinant protein
Peptide
Purified native protein
Other - describe:
5. The immunogen is (check one):
Full length
Partial - specify amino acids:
6. The immunogen is (check one):
WT
Mutant/post-translationally modified - describe:
7. Fusion Partner (e.g., FLAG, KLH, GST, 6-His, etc.):
Antibody Information:
1. Species Immunized:
2. Immunoglobulin Isotype:
3. Epitope (if known):
4. Species Cross-Reactivity:
5. Tested Applications:
WB
ELISA
IF (ICC)
IHC
IP
Other - please specify:
6. Amount Available (ml):
Serum
Purified Antibody
Purification Method
Return Completed Form to:
KSU Research Foundation - 2005 Research Park Circle, Suite 105 – Manhattan, KS 66502-5020
Phone: 785-532-5720 Fax: 785-532-3920 Web: http://k-state.edu/tech.transfer
Page | 4
For Mouse Strains Only
For Targeted Mutation Strain Generation Only:
1. Founder Background:
2. Donor Background:
3. Targeted Gene Name:
4. Strain Nomenclature (if known, as described by the International Committee on Standardized Genetic
Nomenclature for Mice):
5. Description of Strain Generation:
For Transgenic Strain Generation Only:
1. Genetic Background:
2. Genetic Inset Description:
3. Strain Nomenclature (if known, as described by the International Committee on Standardized Genetic
Nomenclature for Mice):
4. Description of Strain Generation:
Strain Description:
What are the strain phenotypes and uses?
Return Completed Form to:
KSU Research Foundation - 2005 Research Park Circle, Suite 105 – Manhattan, KS 66502-5020
Phone: 785-532-5720 Fax: 785-532-3920 Web: http://k-state.edu/tech.transfer
Page | 5
For All Other Research Reagents (including plasmids, recombinant protein, cell lines, etc.)
Brief Summary of the Reagent:
Provide a summary describing the generation and uses of your reagent. Attach plasmid maps if
applicable.
Return Completed Form to:
KSU Research Foundation - 2005 Research Park Circle, Suite 105 – Manhattan, KS 66502-5020
Phone: 785-532-5720 Fax: 785-532-3920 Web: http://k-state.edu/tech.transfer
Page | 6
CREATOR DATA SHEET
K-STATE CONTRIBUTOR(S)
Please note that KSU Research Foundation is now collecting Wildcat ID numbers rather than social
security numbers for security and privacy reasons.
* Note:This contributor will serve as the principal contact with the Research Foundation.
*Name:
Employee ID Number:
Department/Administrative Unit:
Country of Citizenship:
Kansas State University Affiliation (check one):
Faculty
Staff
Student
Work Address:
Work Phone:
Work Fax:
Email:
Home Address:
Name:
Employee ID Number:
Department/Administrative Unit:
Country of Citizenship:
Kansas State University Affiliation (check one):
Faculty
Staff
Student
Work Address:
Work Phone:
Work Fax:
Email:
Home Address:
Name:
Department/Administrative Unit:
Employee ID Number:
Country of Citizenship:
Kansas State University Affiliation (check one):
Faculty
Staff
Student
Work Address:
Work Phone:
Work Fax:
Email:
Home Address:
Name:
Employee ID Number:
Department/Administrative Unit:
Country of Citizenship:
Kansas State University Affiliation (check one):
Faculty
Staff
Student
Work Address:
Work Phone:
Work Fax:
Email:
Home Address:
Please copy and paste the above section or photocopy this page for additional contributors.
Return Completed Form to:
KSU Research Foundation - 2005 Research Park Circle, Suite 105 – Manhattan, KS 66502-5020
Phone: 785-532-5720 Fax: 785-532-3920 Web: http://k-state.edu/tech.transfer
Page | 7
CONTRIBUTOR(S) NOT AFFILIATED WITH K-STATE
If a creator/contributor is not a K-State employee, please provide information below.
Name:
Country of Citizenship:
Position:
Employer:
Work Address:
Work Phone:
Work Fax:
Email:
Name:
Country of Citizenship:
Position:
Employer:
Work Address:
Work Phone:
Work Fax:
Email:
Name:
Country of Citizenship:
Position:
Employer:
Work Address:
Work Phone:
Work Fax:
Email:
Return Completed Form to:
KSU Research Foundation - 2005 Research Park Circle, Suite 105 – Manhattan, KS 66502-5020
Phone: 785-532-5720 Fax: 785-532-3920 Web: http://k-state.edu/tech.transfer
Page | 8
SIGNATURE PAGE
By signing below, each contributor certifies that he or she is a contributor, that the others named herein
are contributors, and that there are no other contributors, to the best of his or her knowledge. You must
notify KSURF of any change of address. If you cannot be contacted, intellectual property protection may
be abandoned and you may not receive any royalties.
* Note:This contributor will serve as the principal contact with the Research Foundation.
* Contributor Signature
Date
Contributor Signature
Date
Contributor Signature
Date
Contributor Signature
Date
Contributor Signature
Date
Contributor Signature
Date
Contributor Signature
Date
APPROVED AT KANSAS STATE UNIVERSITY BY:
Department/Administrative Unit Head
Date
Department/Administrative Unit Head
Date
Department/Administrative Unit Head
Date
ACCEPTED AT KANSAS STATE UNIVERSITY RESEARCH FOUNDATION BY:
J. Ernest Minton, Interim President
Date
Return Completed Form to:
KSU Research Foundation - 2005 Research Park Circle, Suite 105 – Manhattan, KS 66502-5020
Phone: 785-532-5720 Fax: 785-532-3920 Web: http://k-state.edu/tech.transfer