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					                                 Copyright Disclosure Form
             This is a confidential, proprietary, nonpublic university record
              that may not be disclosed outside the university without the
                             approval of MSU Technologies.


Instructions

The purpose of this Copyright Disclosure Form (“Form”) is to provide a written, dated notice of your work
of authorship and comply with Michigan State University’s Copyright Policy. Copyright is a form of legal
protection provided to literary, dramatic, musical, artistic, and certain other intellectual works. Please
contact MSU Technologies (“MSUT”) if you have any questions about the types of works that are
protected by copyright.

Return the original signed Form and any supporting documentation to:

MSU Technologies
Michigan State University
325 E. Grand River, Suite 350
East Lansing, Michigan 48823

The primary author who is responsible for the development of this work should complete the Form.
However, all co-authors listed in Section 1 must also review and sign the Form.
       Please answer the questions with as much detail as possible. Attach additional pages if
        necessary.
       The primary author must sign an original Form.
       Upon receipt, MSUT will date stamp and assign a number to the work for reference purposes.
        The work will then be assigned to a technology manager who will contact the author(s) to
        schedule an interview to further review the details and specifications of the work.
       Authors will need to submit a signed and completed Proceeds Distribution Form to provide royalty
        distribution assignments and detailed author information. This information is necessary to
        distribute royalty payments. Please note that MSUT will make a final determination concerning
        authorship.

       If possible, provide a copy of the work that is the subject of this Form.




                                     For MSUT Use Only
Case No.:                          TM:                                 Date:
                                             MSU Confidential


1. Summary/Overview

Authors
List all authors of the work below. The listed individuals ultimately may or may not fall within the legal
definition of “author.” Place an asterisk (*) next to the name of the person to whom correspondence from
MSUT should be sent.

If any author is an employee of another university, company, or governmental agency, please list that
person in the “non-MSU authors” table below. Please include those who hold joint appointments outside
MSU in this category.

List each MSU author:
                                    First         Primary
Dr/Mr/Ms     Last Name              Name          Department     E-mail                     Phone




List each non-MSU author:
                                    First         Non-MSU
Dr/Mr/Ms     Last Name              Name          Affiliation    E-mail                     Phone




Title of Work
Provide the title of the work.




Brief Description of Work
Provide a brief summary (3-4 sentences) explaining what the work consists of.




Is the work part of a series or larger collection of works?

 Yes.
 No.

Is the work derivative of another work?

 Yes.


                                                                                                 Page 2 of 8
                                           MSU Confidential


 No.

Date the work was completed (MM/YYYY):




2. Funding and Origin of Work

If the work was developed with the use of any research grant/contract funds, please provide funding
source information below.

Non-Federal Funding:
MSU Acct Number        Funding Entity




Federal Funding:
MSU Acct Number        Funding Entity                         Funding Entity Grant Number




Was the work developed using resources, equipment, materials, or staff services of any unit of the
university?

 Yes. (Describe)




 No.


Was the work developed during the course of outside work for pay?

 Yes. (Describe)




 No.

                                                                                               Page 3 of 8
                                            MSU Confidential




Was the work developed with materials, information, or data received from an external source in
exchange for intellectual property rights?

 Yes. (Describe)




 No.


Could anyone else make a claim to this work, including a previous employer or a company for which you
did consulting work?

 Yes. (Describe)




 No.


3. Software

Complete this section only if the work consists of or includes software.

Please indicate whether any third party code is embedded in or accessed by the software when run.

 Third party code is embedded in or accessed by the software. (Please include the name and
  copyright holder, if known, of any open source code, free executable code, public domain code, and
  any other executable or source code not written by any of the authors listed in Section 1 of this Form.
  Also indicate whether the use of third-party code is under a license agreement.)




 This software is completely original code.

 Unknown.

Describe any documentation you prepared in connection with the software (e.g., user’s guide, installation
guide, technical documentation, etc.).


                                                                                               Page 4 of 8
                                            MSU Confidential




The Problem Being Solved
What potential product, process, or service could develop out of this software? What customer problem
would it help to solve (i.e., what is the need)?




Advantages of the Work
Do you know of any other works that are related to the subject matter of this disclosure (i.e., competitive
products or services)? Why is this work superior to competing ways of solving the same problem(s)? If
possible, include information about anticipated competitive advantages of the work and any significant
barriers to commercialization.




How It Works
Describe how your work functions, including details of any components involved. Attach drawings, white
papers, sketches, photographs, graphs, flow charts, etc., to illustrate the work and/or its components.




Level of Development
Describe the current level of development of the software and any plans for any additional development
or testing.




                                                                                                  Page 5 of 8
                                           MSU Confidential




4. Publication/Distribution
Has the work been published or distributed outside of MSU?

 Yes. (Describe nature of publication or distribution (journal, conference name, etc.) and approximate
  date)




 No.

If you answered “Yes” to the previous question, was the disclosure made under a confidentiality, non-
disclosure, or similar agreement limiting the recipient’s rights to disclose?

 Yes.

 No.

Do you intend to publicly disclose the essential elements of the work in the next six months?

 Yes. (Describe the nature of disclosure and anticipated date)




 No.


5. Commercialization Potential

Speculate on what you believe is the commercial potential of this work.

 Don’t know.

 Research or government agency interest only.

 Describe commercial potential in the space provided below, including potential marks and interested
  companies:




                                                                                                Page 6 of 8
                                           MSU Confidential




Contacts
Please list any companies that may be interested in the development and/or distribution of the work.

Name                 Company                      Address/Phone/E-mail




                                                                                               Page 7 of 8
                                            MSU Confidential




DECLARATION

Each MSU author, as listed above in section (1), hereby:

    acknowledges and confirms that the university holds all rights in the work herein disclosed
(“University Work”) under United States copyright law and the university’s Copyright Policy; and

     for the avoidance of doubt by any third parties in connection with the licensing and commercialization
of the University Work, agrees to assign, and does hereby assign, to the university the entirety of his/her
intellectual property rights in the University Work and agrees to execute, upon request of the university,
any and all documents that the university deems necessary to record and/or perfect the assignment of
rights to the university.

Each non-MSU author agrees to promptly notify MSU Technologies of any employment relationship,
contract, or other arrangement which transfers or assigns, by operation of law or contract, any of his/her
rights in the work to any non-MSU entity.

Author Name (print/type)                   Signature                                   Date




Reference:

MSU Copyright Policy:

http://www.hr.msu.edu/documents/facacadhandbooks/facultyhandbook/copyrightedmaterial.htm




Revised March, 2012


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