Invention-Disclosure by ashrafp

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									                                  Invention Disclosure Form
              This is a confidential, proprietary, nonpublic document that
              may not be communicated in any way without the consent of
                   Michigan State University and MSU Technologies.



Instructions

The purpose of this form is to provide a written, dated notice of your invention disclosure and comply with
Michigan State University’s patent and copyright policies. A disclosure also enables MSU to comply with
most industry contractual requirements as well as the requirements of the U.S. Federal Government laws
and regulations as they are applied to university grants and contracts.

An invention disclosure should be completed when something new and useful has been conceived or
developed or when unusual, unexpected, or unobvious research results have been achieved and can be
utilized. The term “technology” refers to all forms of intellectual property, e.g., patents, trademarks, and
copyrights.

Return the original signed Invention Disclosure Form, along with any supporting documentation
(publications, presentations, materials) to:

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


This ID form replaces the Author’s Statement Form.


The Principal Investigator (PI) who is responsible for the development of this technology should complete
the Invention Disclosure Form.
       Please answer the questions, providing as much detail as possible. Add space/rows to applicable
        fields as necessary.
       The PI must sign an original Invention Disclosure Form.
       Upon receipt, MSU Technologies (MSUT) will date stamp and assign a technology number to the
        invention disclosure for future reference purposes. The technology will then be assigned to a
        technology manager who will contact the PI to schedule an interview to further review the details
        and specifications of the invention.




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


1. Summary/Overview

Innovators
List all individuals who helped contribute to the conception of the technology. The people included
ultimately may or may not be legal inventors. Please place an asterisk (*) next to the name of the person
to whom correspondence should be sent.

If any person holds a sole or joint appointment with another university, company, or governmental
agency, please list them in the “non-MSU innovators” table below.

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




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




Title of Invention
If there is no formal name for this technology, please provide a descriptive title that indicates what the
technology is and what task(s) it accomplishes. For example, new software designed to help users
without accounting training to prepare income taxes might be titled “Income Tax Software for Non-
Accountants.”




Invention Description (Non-Confidential)
Provide a brief summary (no more than 3-4 sentences) explaining what this technology is and what it
does but not how it does it. Do not include details that reveal proprietary, competition-sensitive details, or
information that would allow duplication/imitation. Other details should be included in section 4,
Background Information.




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                                              MSU Confidential


Funding Source
Please provide funding source information related to this technology to maintain compliance with
reporting requirements.

Non-Federal Funding:
MSU Acct Number         Funding Entity
(61-XXXX, etc)




Federal Funding:
MSU Acct Number         Funding Entity                            Funding Entity Grant Number
(61-XXXX, etc)




 Check here if this product was developed without support from extramural gifts, grants, and/or
  contracts.

2. Copyright Information

Is this invention disclosure for copyright purposes of a literary, dramatic, musical, artistic, or other
intellectual work?

 Yes.

 No (If no, proceed to section 3, Software Information).

Origin
Please indicate whether this work includes or is built upon work developed and owned by others.

 This work contains material copyrighted external to MSU. If so, enter name of copyright holder(s).




 No. It is not built upon work developed and owned by others.

Distribution
Has the current and/or previous version(s) of this work been distributed or otherwise made available
beyond the individuals listed as innovators or within the project/program that funded the work?

 No one has seen it.

 The work was provided to the following external organization, person, or group:




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                                            MSU Confidential


3. Software Information

Is this technology software or does it contain software?

 Yes.

 No (If no, proceed to section 4, Background Information).

Origin
Please indicate whether this software includes, or is built from, code developed by others. Check and
circle all that apply. Please include any open source software that was used.

 This software is an improvement based upon existing code and was used with / without (circle one)
  a license agreement in place. Enter name of code and copyright holder.




 This software contains third-party code (e.g., a subroutine) and was used with / without (circle one)
  a license agreement in place. Enter name of code and copyright holder.




 This software is completely original code.

 Unknown.

Distribution
Has the current and/or previous version(s) of this software been distributed or otherwise made available
beyond the individuals listed as innovators or within the project/program that funded the development?

 No one has seen it.

 The work was provided to the following external organization, person or group:




4. Background Information

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




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                                            MSU Confidential


Advantages of the Invention
What are other solutions to the problems currently being developed as well as anticipated solutions (i.e.,
the competitive products or services)? Why is this proposed technology a better approach than the
competition? If available, include information about all anticipated sustainable competitive advantages
and any significant barriers to entry.




Additional Documentation (Public Disclosure or Public Use/Sale)
Please provide any articles, presentations, reports, proteins or DNA sequences, engineering
specifications, drawings, test data, assembly or manufacturing procedures, or any other information that
will aid the understanding of this technology. Electronic copies are preferred. Also include all dates of
previous or planned public or commercial use/sale.
Title                             Description                                 Date




5. Detailed Technical Description (Required for patentable inventions only.)

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




Level of Development
Describe the current level of development (concept, proof of concept, prototype, full-scale model, space
qualified, etc.) and plans for any additional development or testing.




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                                            MSU Confidential


Invention Timeframe
Date (MM/YYYY) technology was conceived
(i.e., mental conception of invention)
Is conception date documented in writing (i.e., a lab
notebook)? (YES / NO)
Date (MM/YYYY) of first reduction to practice
(i.e., built or performed the invention)

Discussion Outside MSU
Has this technology been discussed with individuals outside the related project (e.g., in a paper, through
formal or informal presentations)?

 Yes (If so, enter name with whom the technology was discussed and approximate date of
  discussion).




 Other (e.g. MTA, CDA, etc.).




 No.

6. Commercialization Potential

Speculate on what is believed to be the commercial potential of this technology.

 Don’t know.

 Research or government agency interest only.

 May have niche applications and/or limited commercial interest. List potential market(s) and names of
  companies:




 Should have some commercial potential. List potential market(s) and names of target companies:




 Should have significant commercial potential/interest. List potential market(s) and names of target
  companies:




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                                           MSU Confidential


Industrial Contacts
Please include any and all industrial contacts made or to be made related to this technology.
Name                   Company                    Address/Phone/E-mail




Signature and Submission Information

Primary Inventor Name (print/type)         Signature                                  Date




NOTE: Inventors will need to submit a signed and completed “Proceeds Distribution
Form” to finalize the royalty assignments and inventor information.




Revised September 15, 2010


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