ࡱ>  %bjbjEE .''  ]]]qqq8-q7<(DDD47676767676767,9<xb7]D""DDDb7  9w7D 8]47D473E6@6 .4 77075'='=066&]<6DDDb7b7DDD7DDDD'=DDDDDDDDD + :   Confidential Invention Disclosure Form Office of Research Old Dominion 91Ƶ, Ste 200, 4111 Monarch Way, Norfolk VA 23508 ODU Research Foundation Tel: 757-683-5052 Date RecdPI NameODU #  The Old Dominion 91Ƶ Office of Research (OR) reviews and endeavors to license all inventions received from members of the ODU Community. The 91Ƶ will share income resulting from the licensing of inventions with ODUs inventors according to the 91Ƶs Policy on Intellectual Property. This form serves to notify the OR of your inventions, related sponsorship, public disclosure history, and establishes a legal documentation of inventorship. This form should be submitted to the OR when new inventions are conceived and/or reduced to practice before public disclosure. Invention disclosures will not be accepted unless they are submitted on this disclosure form or if the information contained on this form is incomplete. Invention Title Very brief, descriptive & technically accurate Description of Invention Starting with the problems addressed, describe the novelty of outcome, including materials, processes, concepts, algorithms, etc that constitute the invention. Should enable a technically competent person to understand what the invention does and how it works. Attach extra pages & drawings, sketches, data, etc. if necessary [ ] Product [ ] Process [ ] Method [ ] Device [ ] Design [ ] Matter [ ] New use of known drug, product etc [ ] Software [ ] Plant, asexual [ ] Bacteria, altered [ ] Animal, transgenic [ ] Antibody mark all that apply Experimental Verification: -Have you tested the invention? If yes, please explain. -Do you have a prototype? If yes, please explain.Uses of Invention Such as unmet needs, or new services, products, processes, etc. Competitive Advantages Of invention over existing, such as in costs, yields, risk, performance, accuracy, consistency, simplicity, etc Potential Licensees & Competitors Names of companies and products of similar/competing products /services. Potential LicenseesCompetitorsMarket Info Info on potential geographic markets, or market segments & size of market, etc Market segments Geographic Prior Art Mention any relevant patents, publications, products, etc that you are aware of. List specific keywords to use when conducting patent/scientific search of this invention.We have a legal duty to disclose this to US Patent Office Use of Proprietary Technology, Software or Materials. Is this invention dependent on the use of third party patented technology, software or materials for it to function, No Yes if Yes please provide details (was it obtained under an agreement or purchased in the open market?) Date of Invention Lab notebooks, etc must be retained. Provide info on earliest dates of conception & invention, and mention any records you have such as Lab notebooks and location of such. Univ. policy requires that these be submitted to Office of Research if requested. Public Disclosure -Mention date and place of first disclosure, this includes presentations, publications, posting to websites, published theses, discussions with supplier, sponsor, etc Required by Law Identify any disclosures, either written or oral, of the invention that you expect to make to others in the future. Expected date: Title of publication/presentation: Journal name or meeting:  Date Company __________________ ________ Person/Group __________________ ________ Title __________________ ________ Relationship __________________ ________ Other __________________ ________  Date Publication __________________ ________ Presentation ________________ ________ Poster ________________ ________ Theses __________________ ________ Other __________________ ________ Financial Support Please identify the Sponsors, if any, that provided funds or in-kind contributions to support the research. Required to meet legal obligations Please attach copies of grants if any.  Govt. Agency or CompanyAddress & ContactAward # Grant Name Principal Investigator ODURF # Please indicate if work was made without internal/external funds but with use of ODUs resources. Marketing Abstract Please provide a non-confidential, marketable description of your invention. Do not include any enabling information, which could allow practicing the invention without a license. Describe the features, advantages, and benefits of your invention over other similar/competing technologies.   Identification of ODUs Inventors. All persons who have contributed to the conception or reduction to practice of this invention must be identified. I (we) hereby assign and agree to assign all rights, title, and interest to this Invention to Old Dominion 91Ƶ and agree to execute as requested any patent applications, assignments and other documents related to this Invention and to cooperate with Old Dominion 91Ƶ in the protection of this Invention. The undersigned also hereby declare(s) that he/she/they are the true originator(s) of the Invention disclosed herein, and that the Invention arose in the course of work on behalf of Old Dominion 91Ƶ or through the benefit of the use of Old Dominion 91Ƶs facilities, equipment, or other resources. By submitting this disclosure, the individuals named below hereby declare that all statements made herein of their own knowledge are true and that all statements made on information and belief are believed to be true. If there are more than four contributors, please attach additional signature page forms. Use additional sheets if required. All Contributor(s) must sign. Contributor 1 (% contribution)Contributor 2 (% contribution)Name: Please print: (First, Middle, Last)Signature & DateTitle Work conducted atDept/Faculty Work Address  Home Address  Permanent Email Address:Other Email Address:Telephone Business ResidenceBusinessResidence ODU ID #CitizenshipODU ID #CitizenshipContributor 3 (% contribution)Contributor 4 (% contribution)Name: Please print: (First, Middle, Last)Signature & DateTitle Work conducted atDept/Faculty Work Address  Home Address  Permanent Email AddressOther Email addressTelephone BusinessResidence BusinessResidence ODU ID #CitizenshipODU ID #Citizenship Identification of non-ODU Contributors. If any contributor is not an Old Dominion 91Ƶ employee, please provide that outside contributors personal and institutional/corporate addresses. In addition, please provide any contact details of anyone managing the intellectual property of the outside contributor(s). 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