INTELLECTUAL PROPERTY DISCLOSURE (Attach additional sheets as by jamiemccoy

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									                     INTELLECTUAL PROPERTY DISCLOSURE
                                (Attach additional sheets as appropriate)

I.    DESCRIPTIVE TITLE OF INTELLECTUAL PROPERTY
      _______________________________________________________________________

      _______________________________________________________________________

II.   PRIMARY INVENTOR

      1.    Name: ____________________________________________                       ______________
                         Last                       First                    MI         Degree

      2.    Social Security Number:           __________________________

      3.    School and Program:               __________________________

      4.    Campus Mail:                      __________________________

      5.    Campus Phone Number:              _______________________

            Fax Number:                       _______________________

      6.    Home Address:                     ______________________________________
                                                  Street
                                              ______________________________________
                                                  City                      State       Zip

      7.    Home Phone Number: ( ____ ) __________________

      8.    Percent of time employed at University ___________

      9.    Other employment, if any _____________________________________________
            ___________________________________________________________________

      10.   How much time was spent by you personally in making this invention? _________

            ___________________________________________________________________

      11.   Approximately what percentage of the overall invention was created by you?
            (Note: Percentage (%) created by you plus all co-inventors cannot exceed 100%
            in total.)
            ______________

      12.   Signature:   ________________________________                    Date: ________________

            Typed or Printed Name: ______________________________________________
III.   ADDITIONAL INVENTORS (Use a separate page(s) for each additional inventor)

       1.    Name: ____________________________________________            ______________
                          Last                First               MI            Degree

       2.    Social Security Number:     __________________________

       3.    School and Program:         __________________________

       4.    Campus Mail:                __________________________

       5.    Campus Phone Number:        _______________________

             Fax Number:                 _______________________

       6.    Home Address:               ______________________________________
                                            Street

                                         ______________________________________
                                            City                 State          Zip

       7.    Home Phone Number: ( ____ ) __________________

       8.    Percent of time employed at University ___________

       9.    Other employment, if any _____________________________________________

             ___________________________________________________________________

       10.   How much time was spent by you personally in making this invention? _________

             ___________________________________________________________________

       11.   Approximately what percentage of the overall invention was created by you?
             (Note: Percentage (%) created by you plus all co-inventors cannot exceed 100%
             in total.)

             ___________________________________________________________________

       12.   Signature:   ________________________________        Date: ________________

             Typed or Printed Name: ______________________________________________
IV. INVENTION INFORMATION

   1.    BRIEFLY SUMMARIZE THE PURPOSE AND USE OF INVENTION.


   2.    DESCRIBE THE COMMERCIAL APPLICATION OF THE INVENTION,
         POTENTIAL MARKETS AND ANY SPECIFIC INDUSTRY OR BUSINESS
         CONTACT PERSONS WHO MAY BE INTERESTED IN THIS INVENTION.


   3.    WHAT PARTICULAR FEATURES OF THIS INVENTION ARE NOVEL?


   4.    HOW DOES THIS INVENTION DIFFER FROM PRESENT TECHNOLOGY?


   5.    HAS THE INVENTION BEEN, OR WILL BE, DISCLOSED IN ANY
         PRINTED PUBLICATION?   YES ______, NO _______

         If Yes, identify the publication and date.


   6.    DATE INVENTION WAS                           7.     DATE INVENTION WAS FIRST
         CONCEIVED.                                          DISCLOSED TO OTHERS.


   8.    TO WHOM WAS INVENTION                        9.     DATE THE FIRST DRAWING
         DISCLOSED?                                          OR SKETCH WAS MADE.


   10.   DATE OF THE FIRST                            11.    DATE FIRST CONSTRUCTION
         WRITTEN DISCLOSURE.                                 OR MODEL WAS MADE.


   12.   HAS THE INVENTION BEEN TESTED?                     YES ______, NO _______

         IF YES, STATE DATE OF FIRST TEST AND DESCRIBE THE RESULTS.


   13.   HAS THE INVENTION BEEN USED?
         YES ( See below ) _______, NO _______
         YES, EXPERIMENTALLY (State date and details)

         YES, ROUTINELY (State date and details)
14.   WAS THE DEVELOPMENT OF THE INVENTION AIDED IN ANY WAY
      BY A GRANT OR CONTRACT?

      YES ______

      NO _______ If no, omit question numbers 15 and 16.


15.   TITLE OF GRANT OR CONTRACT (If more than one, list each separately).

      ___________________________________________________________________

      SPONSOR NUMBER ___________________

      ACCOUNT NO. _______________________

      AGENCY _________________________________________________________

      ___________________________________________________________________


16.   BRIEFLY DESCRIBE THE PURPOSE OF THE GRANT OR CONTRACT
      AND HOW DEVELOPMENT OF THE INVENTION WAS AIDED.


17.   EXPLAIN BRIEFLY THE USE, IF ANY, OF THE FOLLOWING ITEMS IN
      CONNECTION WITH THE MAKING OF THE INVENTION.

      A.   THE USE OF UNIVERSITY FACILITIES, LABORATORIES, OFFICES,
           ETC.


      B.   THE USE OF UNIVERSITY EQUIPMENT (such as instruments, tools, or
           machinery).


      C.   THE USE OF UNIVERSITY MATERIALS (supplies, reagents, parts, or
           any other materials; if scrap, waste or salvage materials were used, so state;
           give estimated monetary value of materials consumed).


      D.   AMOUNT OF UNIVERSITY FUNDS, OTHER THAN SALARIES AND
           WAGES, WHICH WERE ACTUALLY OBLIGATED OR EXPENDED
           FOR THE PURPOSE OF MAKING INVENTION.
           E.   CONTRIBUTION OF TIME OR SERVICES OF OTHER UNIVERSITY
                EMPLOYEES (state approximate number of hours and type of assistance).


     18.   DESCRIBE A SPECIFIC EMBODIMENT OF THE INVENTION (include
           sketch, drawings, circuit diagrams, photographs, chemical formulas).


     19.   ITEMIZATION       OF     DOCUMENTS       BEING     ATTACHED        TO     THIS
           DISCLOSURE:


     20.   TWO WITNESSES SHOULD SIGN BELOW IN SPACES INDICATED:

           1) Witness: __________________________________          Date: _______________
                                  signature                                month/day/year

           2) Witness : __________________________________         Date: _______________
                                  signature                                month/day/year



IMPORTANT: Once this disclosure has been signed by the inventor(s) (see sections I and
II) and witnesses (see section IV - subsection 20 above), no changes should be made in the
description or drawings. All additions or corrections should be submitted in the form of a
supplemental memorandum particularly referencing this disclosure or in the form of a new
disclosure.

PLEASE NOTE: If funding for project comes from any part of the Department of Defense,
the attached form must be filled out. DOD FORM 882

								
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