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INVENTION DISCLOSURE FORM

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Confidential Information

PREPARATION OF AN INVENTION DISCLOSURE

To preserve potential rights in the United States and in foreign countries, it is important the thoroughly describe your invention, along with the dates it was conceived and reduced to practice through trial and error. This document, if accurately prepared, signed by the inventor(s), and witnessed will be strong evidence to help you obtain and preserve these patent rights. Use additional signed witnessed pages, if necessary.

  1. Descriptive Title of the Invention:
  2. Brief Description of the Invention:
  3. Name all Inventors (all persons who contributed to the conception of the invention; give full names):
    1. __________________________________
    2. __________________________________
    3. __________________________________
    4. __________________________________
  4. Where and how is the Invention to be used? Invention Disclosure AgreementDate: ____________________Initial: ____________________Initial: ____________________
  5. Background
    1. Inventions are usually made during attempts to solve a problem. What problem was solved by this invention.?
    2. Describe how others have attempted to solve this problem. Set forth a brief description of the closest “prior art” (any and all known alternatives to your invention, any patents, printed publications, or publicly known products, processes, equipment, etc.):
  6. Differences between the Invention and the Prior Art
    1. Differences between the Invention and the prior art:
    2. Advantages of the Invention over the prior art: (Advantages can include size, cost, ease of use, etc.)
  7. Confidentiality
    1. When, how and where do you intend to first make public the essence of the invention?
    2. Identify all printed publications (U.S. and foreign) in which the Invention is described in whole or in part and indicate date of publication and attach photocopies of any publications. This can include publications by yourself, coinventors, competitors or others.
    3. Identify all patent applications and patents (U.S. and foreign) in which the Invention is described in whole or in part (attach photocopies):
    4. Identify documents, drawings, reports, papers, lab books, etc. in which the invention is described in whole or in part (attach photocopies):
    5. Please set forth the names of all persons (other than the Inventors), companies, institutions and government agencies to whom the invention has been disclosed. Set forth the dates of this disclosure:
  8. Use of the Invention:
    1. Date of first use: _______________________
    2. Date of first use in U.S.: _______________________
    3. Date of first public use: _______________________
    4. Date of first public use in U.S.: _______________________

    Note: If there is no such date, indicate “none” in the appropriate space.

  9. Trademarks used, or to be used, in connection with the Invention:
  10. Identify all patent applications and patents of the Inventor(s) named in Section II.
  11. X. Please list below all sources of funding for materials, equipment and/or manpower involved in making the invention (check where appropriate):_____All funds from unrestricted University/ Departmental budget.
    _____Some / all (circle one) funds from federal or non-profit granting agencies:

    Agency ________________________________       Grant No. _______________

    Agency ________________________________       Grant No. _______________

    _________Some / all (circle one) funds from other companies organizations.

    Company/Organization: ________________________________

    Grant or Contract No. ________________________________

  12. Identify all foreign countries where patent protection is, or may be, desired (this matter must be considered now or foreign patent rights may be lost)
  13. If the Invention incorporates or is used in combination with a computer program, describe the computer program briefly below:
  14. If there are any plans to license or assign the Invention (or patent), describe briefly below:
  15. Please list any commercial companies you feel are/should be interested in your discovery (names of individuals at companies are extremely helpful):
  16. Provide any other information which you feel is relevant to the Invention or to the protection of exploitation of the Invention:
  17. Provide a detailed description of the Invention and how it functions (include drawings, sketches, and flowcharts if appropriate); describe the preferred embodiment of the Invention; describe the inventive concept in broad or generic terms; describe operation of the Invention through one complete cycle:

Signatures and Dates

Signatures and Dates are extremely important as to proof of conception and reduction to practice. All documents related to the description of the invention should be signed and dated by the inventor and witnessed by someone competent to understand the invention and trustworthy so there is no disclosure. Accordingly, this document should be signed dated, and witnessed.

Signature(s) of the Inventor(s):

  1. ______________________________        Address: __________________________
    (signature)
  2. ______________________________        Address: __________________________
    (signature)
  3. ______________________________        Address: __________________________
    (signature)
  4. ______________________________        Address: __________________________
    (signature)

Witnesses:

We, the undersigned, have read this Invention Disclosure and understand its contents.

_____________________________________        ___________________________
(signature)                                                                   (date)

_____________________________________        ___________________________
(signature)                                                                   (date)

Inventor(s) and Witnesses should initial and date the bottom of each page of the Invention Disclosure and all exhibits attached hereto.