INVENTION/TECHNOLOGY DISCLOSURE FORM
This Space is for Office Use Only.
Date Rec’d.: _________________________________
File No.: ____________________________________
Appt. Date: __________________________________
1.
Title of invention/technology:
2.
Contact information of each investigator substantively involved with the invention/technology and a brief
description of their role. Final inventors will be determined by the law firm at the time of patent filing.
Please fill in the name in appropriate table below with a few words regarding their role in the invention and
complete the detailed contact information on the last two pages of this document. We need this information to
properly begin the review process.
a. WSU affiliated investigators:
INVESTIGATOR’S
NAME
BRIEF DESCRIPTION OF ROLE IN THE DEVELOPMENT OF THE TECHNOLOGY
b. Non- WSU affiliated investigators:
INVESTIGATOR’S
NAME
BRIEF DESCRIPTION OF ROLE IN THE DEVELOPMENT OF THE TECHNOLOGY
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3.
Is the invention/technology a new process or method, composition of matter or device? Or is it a new use for, or
an improvement of, an existing product or process? Kindly provide a narrative description. (Use additional
sheets to elaborate, if necessary.)
4.
How does the invention/technology differ from existing technology? Why did you create it? What advantages
does it possess over existing technology? What unmet need does your invention/technology fill?
5.
If not previously stated, please identify the function and possible commercial uses of the invention/technology.
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6.
Are there disadvantages to or limitations on the invention/technologies’ usefulness? Please explain.
7.
Are there current or future publications planned--theses, reports, pre-prints, reprints, abstracts, public lectures,
etc.--pertaining to the invention/technology? Please list with publication dates, and attach copies insofar as is
practical. Include manuscripts for publication (submitted or not), news releases, internet communications,
feature articles and items from internal publications. Also, please provide any information regarding future
publication plans, including possible dates of submission/acceptance.
8.
Are laboratory records and/or data available? Give reference numbers and physical locations, but do not enclose.
9.
Please identify any related publications or patents known to you.
10. If there have been public disclosures (e.g., a presentation, abstract, funded grant application), please state the
date, place and circumstances of such disclosures.
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11. Was the work that led to the invention/technology sponsored by another organization or the government?
______ Yes
______ No
If yes, please identify in the blanks below all sources of public or private funding other than from WSU (e.g.,
contracts or grants from federal or state agencies, foundations, public or private organizations or industry), and
submit a copy of the relevant invention/technology or intellectual property sections of each contract or agreement
with this disclosure.
a. Title of Government Agency: _____________________________________________________
Grant/Contract No. ______________________________
Principal Investigator ______________________________Phone _________________
b. Name of Industrial Sponsor: ______________________________________________________
Grant/Contract No. _______________________________
Principal Investigator ________________________________Phone _________________
c. Other sponsor(s):__________________________________________________________________
Grant/Contract No. _______________________________
Principal Investigator __________________________________ Phone ________________
12. Has any commercial interest been shown to date? Identify companies, with addresses, names or
representatives and phone numbers, if known to you.
13. Please identify any firms not listed above which would likely be interested in the invention/technology.
14. Give the approximate date or period of time when the invention/technology was first conceived; first
described in writing; and first made and reduced to practice.
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15. Please specify the nature of University support (including salary, funds, facilities, services, and/or
equipment).
16. During the course of your work on this invention/technology, were you salaried with or employed by any
organization or entity that may have a right to this technology?
_______ Yes
_______ No
If yes, please attach a statement of particulars.
17. Did you use proprietary materials owned by another organization to make this invention/technology?
(Examples of proprietary materials: confidential information; biological materials such as cell lines,
transgenic animals, vectors, or genetic sequences; chemical compounds; and software or computer
source code). If so, please attach a copy of the documentation or agreement which covered the transfer
of such material to you or the University.
18. Please list two individuals on campus or in the immediate vicinity (please provide department if on
campus, and address if off-campus) who are qualified to comment on the scientific content of your
invention/technology and/or its commercial potential. (Please attach an extra copy of the disclosure for
each reviewer over two if including more than two names.)
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*****************************
Please do not submit this disclosure without department/dean signatures as appropriate or without the signatures of all
persons named as investigators in item 2. If more than one investigator, please indicate percent of contribution.
SIGNATURES:
% OF
CONTRIBUTION:
DATES:
WSU AFFILIATION?
YES
_____________________________ __________ __________
INVESTIGATOR
NO
OTHER
INSTITUTION
NAME (if other)
x
_____________________________ __________ __________
INVESTIGATOR
_____________________________ __________ __________
INVESTIGATOR
_____________________________ __________ __________
INVESTIGATOR
_____________________________ __________
CHAIR (Need all if multiple departments)
_____________________________ __________
CHAIR
_____________________________ __________
DEAN (Need all if multiple departments)
_____________________________ __________
DEAN
WSU File No: __________
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WSU INVESTIGATOR INFORMATION
To facilitate potential payments to investigators, maintenance of the Technology Transfer Office
database and to ensure the accuracy of legal documents, please supply the following information.
1.
Investigator Name ____________________________ Citizenship _______________If not U.S. citizen
indicate visa type___________________
and check the following:
___ Nonresident alien
___ Resident alien
Title_____________________________________________Degree__________
Department______________________Division__________________________________
WSU Address ________________________________Phone _________ Fax _________
Home Address________________________________ Phone______________________
E-mail ______________________
2.
Investigator Name ____________________________ Citizenship _______________If not U.S. citizen
indicate visa type___________________
and check the following:
___ Nonresident alien
___ Resident alien
Title_____________________________________________Degree__________
Department_______________________Division_________________________________
WSU Address _________________________________Phone _________Fax_________
Home Address_________________________________ Phone_____________________
E-mail ____________________
3.
Investigator Name ____________________________ Citizenship _______________If not U.S. citizen
indicate visa type____________________
and check the following:
___ Nonresident alien
___ Resident alien
Title_____________________________________________Degree__________
Department_______________________Division__________________________________
WSU Address___________________________________Phone_________Fax_________
Home Address___________________________________Phone____________________
E-mail ____________________
4.
Investigator Name ____________________________ Citizenship _______________If not U.S. citizen
indicate visa type____________________
and check the following:
___ Nonresident alien
___ Resident alien
Title_____________________________________________Degree__________
Department_______________________Division__________________________________
WSU Address___________________________________Phone_________Fax_________
Home Address__________________________________ Phone_____________________
E-mail ____________________
*Home address is necessary to comply with certain patent office requirements.
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NON-WSU INVESTIGATOR INFORMATION
Investigator(s)
Name
Home Address
Email
Citizenship
Phone No.
*Home address is necessary to comply with certain patent office requirements.
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Non-WSU Institution/Contact
No.