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UNIVERSITY OF PENNSYLVANIA CENTER FOR TECHNOLOGY TRANSFER INVENTION DISCLOSURE FORM CTT INTERNAL USE Docket #: Date: Complete: Assigned: INSTRUCTIONS: This Invention Disclosure Form is a form for use by University of Pennsylvania faculty, staff, and students when they must report the creation of intellectual property. Upon receipt of this form and the required supporting materials, your invention disclosure will be officially docketed and assigned to a director in the CTT with the most relevant scientific and commercial background. This completed Invention Disclosure Form and supporting materials should be HAND DELIVERED to the Center for Technology Transfer, 3160 Chestnut Street, Suite 200, in a sealed envelope marked “CONFIDENTIAL” and directed to the attention of “Director, Intellectual Property.” To request a CTT courier pick-up, please go to our web-site: www.ctt.upenn.edu. If you have any questions, please feel free to call the Director of Intellectual Property, at 215-573-4508. School of Medicine Faculty: Please note: your invention disclosure may be reviewed by the School of Medicine Intellectual Property Committee. REQUIRED INFORMATION: ATTENTION: YOUR DISCLOSURE WILL NOT BE REVIEWED UNTIL THE INFORMATION BELOW AND ANY SUPPORTING MATERIALS ARE SUBMITTED TO CTT 1.) Date Submitted: ____________ 2.) Disclosure Title:________________________________________________________________________________________ 3.) Description of Technology (VERY IMPORTANT): CTT cannot review an invention disclosure until it has been fully completed On a separate page and on computer disc if possible, please provide the following items necessary for CTT to asses the technical merit and commercial potential of your invention: a.) A 2-5 page concise description of the invention including: i.) A brief summary ii.) Stage of development iii.) Potential commercial uses and applications iv.) Other similar technologies and competing products v.) Advantages over other similar technologies and products b.) Attachments: i.) Any manuscripts or grant applications ii.) Any related publications and patents by you and others in the field iii.) A copy of the Curriculum Vitae (CV) of all contributors 4.) Is this invention related to a prior invention disclosed to CTT? No Yes a.) If Yes, prior docket number:__________ Title:_________________________________________________________ 5.) Was the invention developed with the use of grant or contract funding? Yes: Federal Award Number and PI Name:_________________________________________ a.) Federal Funding: No b.) Sponsored Research: No Yes: Sponsor Name and PI Name:___________________________________________ 6.) Was the invention developed under a formal Collaborative Research Agreement with a third party or using biological or other proprietary materials obtained from a third party under a Material Transfer Agreement? Yes: Institution/Corporation: _____________________________________ a.) Collaborative Research Agreement: No b.) Material Transfer Agreement: No Yes: Institution/Corporation: __________________________________________ 7.) Please provide information about the following critical dates related to this invention: a.) Has the invention been disclosed or presented to others including posting on the Internet? No Yes: Date disclosed:_________ Description:_____________________________________________________ _____________________________________________________________________________________________ b.) Has a description of the invention been included in an abstract or manuscript submitted for publication? No Yes: Expected publication date: ___________ Description:__________________________________________ _____________________________________________________________________________________________ c.) Has a description of the invention been included in a grant application or grant report? No Yes: Date submitted: __________ Expected funding date: ____________ Funder:_______________________ Please provide a copy of any presentation, internet posting, manuscript, abstract or grant application with this form. UNIVERSITY OF PENNSYLVANIA CENTER FOR TECHNOLOGY TRANSFER INVENTION DISCLOSURE FORM 8.) Please answer the following questions regarding potential commercialization of the invention: a.) What products, processes or services may result from the technology? _________________________________________________________________________________________________ b.) Are there any colleagues whom you know to be working in complementary areas of research? _________________________________________________________________________________________________ c.) Do you know of any companies that may have interest in licensing your invention? _________________________________________________________________________________________________ d.) Are there any companies that you DO NOT want your invention licensed to? _________________________________________________________________________________________________ 9.) Do you have an appointment with the VA? No Yes 10.) Do you have an appointment with CHOP? No Yes 11.) Contributors: I/we submit this invention disclosure in compliance with University of Pennsylvania policies. a.) Required primary contact information: Printed Name: Signature and date: Citizenship: School and Dept: Phone, Fax and E-mail: Home Address*: b.) Other contributors (attach additional sheet if necessary): Printed Name: Signature and date: Citizenship: School and Dept: Phone, Fax and E-mail: Home Address*: Printed Name: Signature and date: Citizenship: School and Dept: Phone, Fax and E-mail: Home Address*: *Home address necessary to comply with certain patent office requirements. Print Me Save Me