CASE NUMBER (OTT USE ONLY)
NEW TECHNOLOGY DISCLOSURE
This form should be submitted to the Office of Technology Transfer at Upstate by SUNY Upstate faculty, staff, students and
their collaborators to disclose inventions and discoveries. The forms submitted must contain original signatures and preferably
will be accompanied by an electronic copy of the form and any attachments.
1. Title of disclosed technology - Please provide a brief, descriptive title that does not reveal any unique or novel features.
2. Primary Contact - This individual will be the point person for all correspondence related to the technology. Please list this
individual first in Section 12.
3. Public Disclosure – Has/have the unique or novel feature(s) of the technology been, or will they be, publicly disclosed in
some manner? If yes, please indicate below the type(s) of disclosure and attach print and/or electronic copies of the relevant
communication(s), presentation(s) and publication(s).
a. Journal
Yes
No
Date (Actual or
Expected): / /
Journal title:
b. Conference
Yes
No
Date (Actual or
Expected): / /
Conference title, location and date:
c. Poster or oral
presentation
Yes
No
Date (Actual or
Expected): / /
Location and date:
d. To Industry
Yes
No
Date (Actual or
Expected): / /
Company and date:
e. On line
Yes
No
Date (Actual or
Expected): / /
URL of disclosure and date posted:
f. In grant proposal
Yes
No
Date (Actual or
Expected): / /
Funding agency and data submitted:
4. Prototypes and/or samples - Are prototypes and/or samples available for testing and/or
demonstration? If yes, please describe what is available.
Yes
No
N/A
5. Key words - Please provide approximately 5 key words related to the technology.
6. Sponsorship - What funds (federal, state, foundations, industry, gifts, Upstate funds, etc.) supported the work leading to
this technology. Please list all sources of funding below.
Name of Sponsor(s)
% Contribution to
Technology
RF or Campus
Account Number
Sponsored Assigned
Identification Number
Office of Technology Transfer | WH 1109C | 750 E. Adams St., Syracuse, NY 13210 | (315) 464-7613 | techtransfer@upstate.edu
7. Third-Party Obligations - Was confidential information or a biological, chemical or physical
material or substance obtained from others used to create this invention?
If yes, was a Material Transfer or Confidentiality agreement involved? Please attach a copy of
any such agreement.
Yes
No
Yes
No
8. Prospects for Commercialization - Please list any companies you think would be particularly interested in the
technology, or which have already inquired about it. Add additional sheets if necessary.
Company Name
Contact Name
Contact Information
9. Brief summary of the technology - Please write or copy and paste here an abstract summarizing the technology.
10. Background – Are you aware of or familiar with any related work, publications or patents by
others or yourself? If so, please provide details below.
If the technology is software, is it a modification to an existing work or does it incorporate the
code, data, files of others? If so, please provide details below.
11. Technology Portfolio – Is this technology related to or does it build on technologies that have
previously been disclosed and/or patented by Upstate or any other institution(s)? If yes, please list
any previous disclosures and patents, and identify the other institution(s), if any.
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Yes
No
Yes
No
Yes
No
Revised July 9, 2015
12. Disclosing parties
For potentially patentable technologies: List only those who contributed to the conception of the technolog. Under US
patent law, an “inventor” is one who makes a material contribution to the subject matter of at least one claim of a patent.
Inventors do not include those who merely suggest and idea of a result rather than the means of accomplishing it, nor do
they include those who merely carry out experiments planned wholly by another. Therefore, a final determination of who
to list as “inventors”, both on any patent application and on any patent that ultimately issues, will be made by Upstate’s
patent counsel applying the legal standards for inventorship.
Note: Names should be listed in the order that they should appear on the patent application, if filed.
Original signatures and complete contact information are required.
Percent contributions should sum to 100.
In the case of computer software: Identify all individuals who have shared in the authorship of the software, and made
a significant intellectual contribution to what are believed to be the novel or non-obvious aspects of the software
described in the disclosure.
If there are more than five disclosing parties, append extra sheets.
1.
Primary Contact Name:
Upstate Affiliation:
Dr.
Faculty
Mr.
Staff
Ms.
Student
Job Title:
Citizenship:
Home Address:
Home Telephone:
% Contribution to the technology (sum to 100):
Home Email:
%
Nature of contribution:
Mobile Telephone/Pager:
Department
Campus/Work Address:
Dean
Campus/Work Phone:
Chair
Campus/Work Fax:
Developer’s Signature:
2.
Name:
Dr.
Upstate Affiliation:
Date:
Mr.
Faculty
Ms.
Staff
Student
Job Title:
Citizenship:
Home Address:
Home Telephone:
% Contribution to the technology (sum to 100):
Home Email:
%
Nature of contribution:
Mobile Telephone/Pager:
Department
Campus/Work Address:
Dean
Campus/Work Phone:
Chair
Campus/Work Fax:
Developer’s Signature:
Date:
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Revised July 9, 2015
3.
Name:
Dr.
Upstate Affiliation:
Mr.
Ms.
Faculty
Staff
Student
Job Title:
Citizenship:
Home Address:
Home Telephone:
% Contribution to the technology (sum to 100):
Home Email:
%
Nature of contribution:
Mobile Telephone/Pager:
Department
Campus/Work Address:
Dean
Campus/Work Phone:
Chair
Campus/Work Fax:
Developer’s Signature:
4.
Name:
Dr.
Upstate Affiliation:
Date:
Mr.
Ms.
Faculty
Staff
Student
Job Title:
Citizenship:
Home Address:
Home Telephone:
% Contribution to the technology (sum to 100):
Home Email:
%
Nature of contribution:
Mobile Telephone/Pager:
Department
Campus/Work Address:
Dean
Campus/Work Phone:
Chair
Campus/Work Fax:
Developer’s Signature:
5.
Name:
Dr.
Upstate Affiliation:
Date:
Mr.
Faculty
Ms.
Staff
Student
Job Title:
Citizenship:
Home Address:
Home Telephone:
% Contribution to the technology (sum to 100):
Home Email:
%
Nature of contribution:
Mobile Telephone/Pager:
Department
Campus/Work Address:
Dean
Campus/Work Phone:
Chair
Campus/Work Fax:
Developer’s Signature:
Date:
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Revised July 9, 2015
13. Additional information about your technology - The following information is not necessary at this point, as we can
explore the answers to these questions later. However, even short answers to the questions below will accelerate our
evaluation of your technology and its commercial potential and patentability, and help us better find and market it to potential
commercial partners. Please use as many additional sheets as necessary if you do provide answers to some or all of the
questions below.
A. What problem does your technology solve, and for whom?
B. How are people dealing with this problem now, and why is that not good enough?
C. How does your technology solve the problem, and what evidence do you have that it works?
D. Why will people want to use your technology instead of current solutions? Will it be faster, cheaper, safer, or better in
some other way?
E. Do you know of any obstacles to the commercialization of your technology, its regulatory approval or its adoption by
customers?
F. Is there anything else we should know about the technology that is not in the answers above or in the attachments?
14. Please attach to this disclosure any additional documentation you have related to the technology being disclosed,
such as any draft manuscripts, presentations, and experimental data and figures.
Office of Technology Transfer
Upstate Medical University
Weiskotten Hall 1109C
750 East Adams St.
Syracuse, NY 13210
Telephone: (315) 464-7613
Fax: (315) 464-5564
Email: techtransfer@upstate.edu
Web: http://www.upstate.edu/techtransfer
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Revised July 9, 2015