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					TTO Docket no.                  UNR/DRI Technology Transfer Office
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Date Received  / /              Invention and Technology Disclosure

The purpose of this Invention and Technology Disclosure is to record what was invented and the circumstances
under which the invention was made or conceived. It provides the basis for determining the patentability and for
drafting a patent application. This disclosure is a legally important document which should be prepared
carefully. An invention is a novel and useful idea relating to processes, machines, articles of manufacture and
compositions of matter. It may cover such things as new or improved devices, products and processes. To be
patentable, the invention must not be obvious to a worker with average skills in that particular field. In addition,
it must not have been used by others in this country, or patented or described in a printed publication anywhere,
prior to the date of conception.

An Invention and Technology Disclosure should be made when something new and useful has been conceived or
developed, or when unusual, unexpected, or non-obvious research results have been achieved.



1. Title of the Invention:




2. Technical Description of Invention:
Please provide or attach a brief description. Inventions could include a new process, products apparatus, composition
of matter, living organism, or an improvement to (or new use for) a thing that already exists. (Sketches, drawings,
photos, reports and manuscripts will be helpful.) (Expand or use additional sheets and attach descriptive materials to
expand answers to questions.)




3. Obligations to Third Parties
What funds supported the work leading to conception or reduction to practice of this invention? (Include federal, non-
federal, foundation and industry funding, gifts, internal funds, etc.) If none, so state.

Contract/Grant No.                             Sponsor                                  P.I.
Contract/Grant No.                             Sponsor                                  P.I.

Please indicate any relevant OSPA account numbers:



4. Stage of Development
Describe the current stage of research, (e.g. prototype, in vitro data, model system and indicate the additional steps
needed for reduction of concept to practice).




5. Commercial Interest
List commercial companies you feel might be interested in this invention (names of individuals at companies are very
helpful).




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6. Public Disclosures, Public Sale
Has invention been disclosed in an abstract, paper, talk, news story or a thesis?
Yes ( )      No ( )
For past printed disclosures, include date of proposal or manuscript submission, date of publication, and any
information you have on electronic publication of the journal. For past oral disclosures, include date of conference,
convention speech, etc. and indicate if any information was distributed prior to the presentation. For electronic
disclosures or www postings, include the date of electronic publications.

If yes, provide disclosure date and enclose a copy of written material.


Do you plan to disclosure information in the future?
Yes ( )      No ( )
For future printed disclosures, include date of proposal or manuscript submission, date of proposal publication, and any
information you have on the proposed electronic publication of the journal.

If yes, describe and give dates.
__________________________________________________________________________________________
Has there been any public use or sale of products embodying this invention?
Yes ( )       No ( )
If yes, describe and give dates




7. Inventors’ Contact Information:
Generally an inventor is an individual who has conceived an essential element of the invention, either independently or
jointly with others, during the evolution of the invention concept. For software, a developer is an individual who wrote
the code. It is important to name only the correct inventors or the patent will be invalid. Include the names of all
presumed inventors or developers. Because inventorship is a legal determination based on the claims of a patent,
named inventors may change from the original disclosures.

(Add additional if more inventors)
1. Name:
Email:                                                               Position
Work Phone:                                                          Dept:
Work Address:

Home Address:

Country of citizenship:

Signature:                                                            Date:

2. Name:
Email:                                                               Position
Work Phone:                                                           Dept:
Work Address:

Home Address:

Country of citizenship:

Signature:                                                            Date:




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