Invention Disclosure Form

Feb. 4, 2004

Submitted by:
Descriptive Title:
Instrument or Project to which Invention Relates:

I. INVENTOR(S)
A. Name Citizenship
Mailing Address
B. Name Citizenship
Mailing Address

II. CONCEPTION OF INVENTION
A. Date of first drawing where located
B. Date of first written description where located
C. Date of first oral disclosure to whom

III. CONSTRUCTION OF INVENTION
A. Date completed by whom made
B. Has first model been retained
C. Where can model be found

IV. TEST OF DEVICE
A. Date of test Witness
B. Results

V. PUBLICATION
A. Has description been published Date of Publication
B. Title of Publication

VI. SALE OR PUBLIC USE
A. Has device been sold Date
B. Use publicly Date

VII. RELATED PRINTED PUBLICATIONS, PATENTS, PATENT APPLICATIONS, NAME OR NUMBERS OF SUCH MATERIAL

VIII. WAS INVENTION MADE UNDER GOVERNMENT CONTRACT
Conceived YES NO Constructed YES NO

CONTRACT No.

IX. SIGNATURE(S) OF INVENTOR(S)
1. Date

2. Date
SKETCH OF INVENTION (ATTACH)


(This sketch may be made in either ink or pencil. Illustrate your invention as clearly and completely as possible. Where necessary or convenient employ additional separate sketches or drawings of the invention. Any such separate sketches and drawings should be fastened permanently to this page. List and identify on this page each such attached sketch and drawing. On the sketches and drawings number the different parts of the invention mentioned in the description. Show all parts which cooperate to achieve your purpose. Include graphs, tables, circuit diagrams, flow charts, chemical formulae, equations, etc., which are involved in and are helpful in understanding the invention.)


PURPOSE OF INVENTION (ATTACH DESCRIPTION)

(Explain the results sought to be accomplished, difficulties overcome or eliminated and advantages to be gained by the invention.


DATE ___________


Name(s) of inventors:

Name ____________________________________________

Title _____________________________________________

Tel (voice) _________________________________________

Tel (fax) ___________________________________________

Work address _______________________________________

Home Address _______________________________________

1. Please describe the invention briefly. If possible, attach a manuscript, a research proposal, a sketch (with all elements numbered and described herein), a drawing or any other materials that would assist in the understanding of the invention.





2. Has the invention been reduced to practice? If so, approximately when?





3. Identify and describe the closest technological development, either in the U.S. or abroad, that you are aware of. Such technology may have been described in any patent or publication, or presented at a public talk or trade fair, or be on sale now or in the past or near future.




4. Do you know if anyone else has invented something similar which is not yet publicly available? If so, please identify and describe it.





5. Please distinctly specify the differences between your invention and the closest prior technology. What advantages does your invention provide over the prior technology? What defect(s) does it overcome? What problem does it solve?





6. What are all possible uses for the invention? Please speculate reasonably on any additional uses that your invention may have, either by itself or in combination with other known, or as yet unknown, technology.






7. What is (or are) the best way (or ways) of carrying out your invention? (Include in the description any peculiar, necessary or unusual properties, characteristics or functions of such parts of the invention and any other special conditions, such as temperature, pressure, dimensions, proportions and the like, which are important to the operativeness of the attainment of the purpose of the invention. Include any chemical formula or electrical computation necessary to an understanding of the invention. Attach hereto all original and preliminary written descriptions of this invention.)

If a product (chemical or otherwise), what are the optimum materials and proportions? If a process, what are the optimum conditions and parameters?





8. Are there any disadvantages or problems with your invention? Can they be overcome? How?





9. Have you or any of your collaborators described this invention or a similar invention in whole or part in manuscripts, reports, grant applications, theses, abstracts, oral presentations, demonstrations, or sales catalogues? If so, describe each event with dates and authors.





10. Have any patent applications been filed on closely related inventions? Identify them, if possible.




11. Has there been a public use or an offer for sale? When? What were the circumstances?





12. Are there any written records such as laboratory notebooks, etc., in which the invention is described? Where can they be found? Indicate location, custody, etc., of the records, starting with the earliest ones.






13. Are there any witnesses who can corroborate the making of the invention, from the early days of conception to the reduction to practice? Please give their names, addresses and telephone numbers.





14. Are you planning any disclosure of the invention in the future? Is there any imminent publication, or oral presentation, or showing or offer of sampling or sale of the invention? Please give approximate dates and locations.





15. Who was (or were) the individual (or individuals) associated with the making of the invention? Please give his/her name(s), address(es) and telephone number(s). Please indicate their contribution(s): proposal, conception, experimentation, useful or crucial suggestions, etc. If in doubt, include the name(s).





16. Who sponsored or paid for the work that led to the invention or part thereof?

a. U.S. Government agency(ies):

b. Industrial sponsor (please enclose relevant patent sections from the contract if available):



c. Other (self, university, private individual, etc.):





17. Has there been any commercial interest in this invention? Please name companies and specific persons, if available.





18. Can you think of any other commercial firms who may be interested in your invention?





19. Would the invention have market potential in countries other than the U.S.? Which countries?






20. Name(s), address(es) and telephone number(s) of person(s) who may be contacted further about the invention:





21. Signature(s) and date(s) of person(s) making this disclosure:


__________________________________ Date: ___________


__________________________________ Date: ___________



__________________________________ Date: ___________


__________________________________ Date: ___________



22. Signature of person witnessing this disclosure, including date signed:

I have read and understood the foregoing disclosure.


_________________________________________________

Date: __________________________________________

Name: __________________________________________

Title: ____________________________________________
 

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