invention - innovation.miami.edu · disclosure office use only ... inventors filing invention...

IDF201701111630 1 CONFIDENTIAL

INVENTION DISCLOSURE

Office use only

Case Number

UMIP-

Section 1: GENERAL INFORMATION

1.1 TITLE OF INVENTION (do not exceed 100 characters)

1.2 PLEASE LIST THE NAMES, PRIMARY DEPARTMENT AFFILIATION AND CONTACT ADDRESSES OF ALL

INVENTORS FILING INVENTION DISCLOSURE (An INVENTOR or CO-INVENTOR is an individual who has conceived or made Intellectual Contribution to develop essential elements of the invention(s).

NAME (Last, First) POSITION ADDRESS TELEPHONE FAX

The University must comply with strictly enforced reporting requirements in order to remain eligible to receive grants and other sources of funding. Please complete the following questions as carefully and completely as possible.

1.3 PLEASE PROVIDE INFORMATION ON GRANT SUPPORT USED FOR DEVELOPING THE INVENTION

If any support (funding, salary, supplies, etc.) was received during the development of the invention by any Federal, corporate (i.e., sponsored research), research foundation, University of Miami, etc., please them in the table below:

CONTRACT/GRANT NUMBER SPONSOR UM ACCOUNT # PRINCIPAL INVESTIGATOR

1.4 Are any intellectual property arrangements associated with the funding/support received? Certain sources of funding or support require the sharing of any revenue generated from an invention. For

example, list any sponsor or foundation that could receive a percentage of potential royalties on commercialized inventions. If you are not certain, please contact the Office of Research Administration to confirm.

Yes No If yes, please provide details:

UNIVERSITY OF MIAMI INVENTION DISCLOSURE CONFIDENTIAL

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1.5 Was this invention supported or funded in any way through a philanthropic gift (either from an individual, foundation, or company)?


1.6 Were any of materials used in this work (reagents, animals, software, etc.) obtained from outside

investigators? This includes other labs at the University as well as labs apart from the University of Miami. If so, please provide the name of collaborator, name of organization, and nature of the materials used.


1.7 If the invention requires any commercial reagents to work, please describe the source and nature of such below. These might include materials, methods, reagents that are subject to "research-use only" agreements (e.g., EGFP) or previously patented materials. If you need assistance in searching for patents, please note this in the space below.


1.8 Were any University of Miami facilities or resources used during the development of the invention?


1.9 CONCEPTION AND PUBLIC DISCLOSURE OF INFORMATION RELATING TO THIS INVENTION

Date References/Comments (Please indicate, Place, Date, Names of individuals, journals/periodicals or forum of presentation. Use a separate sheet if necessary.)

a. Date and place of conception of the

invention. (Please indicate if this has been documented.)

Indicate place of conception of the idea and refer to the

laboratory note book etc.

b. First publication containing description to

enable a person, skilled in the field, to understand and make use of the invention (include theses, and date of submission and publication.)

Author, Journal, Vol. (Number): Pages, Month, Year.

c. First public oral disclosure of invention sufficient to enable a person, skilled in the field, to understand and make use of the

invention

Presentor, Place, Date, Forum.

d. If the invention is unpublished and undisclosed, provide the anticipated publication, oral and electronic disclosure

date and any submissions made for potential publication.

Author, Journal, Vol. (Number): Pages, Month, Year.

Presentor, Place, Date, Forum.


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1.10 HAS THE INVENTION BEEN REDUCED TO PRACTICE? Yes No

If yes, please give the date and manifestation of first reduction to practice.

1.11 IS THE INVENTION SUBJECT TO ANY PRIOR AGREEMENTS SUCH AS MATERIAL TRANSFER, CLINICAL TRIAL, CONSULTING CONTRACT, DRUG STUDIES, ACCEPTANCE OF MATERIAL FROM COLLABORATORS,

ETC.? Yes No

If yes, please give the date and manifestation of first reduction to practice.

1.12 DO ANY INVENTORS ON THIS DISCLOSURE HAVE A FINANCIAL INTEREST, OBLIGATION,

PROPRIETARY INTEREST, AND/OR ANY OTHER OBLIGATION FOR WHICH A POTENTIAL CONFLICT OF INTEREST MAY EXIST? Yes No If yes, please list the Inventor(s), the company, and the nature of relationship.


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Section 2: TECHNICAL INFORMATION

2.1 COMPLETE DESCRIPTION OF INVENTION

(Describe the invention in sufficient details, not exceeding 4900 characters, such that the description should enable a person having ordinarily skill in the field to understand and reproduce the invention. The information provided essential to complete thorough patent and literature searches, and patentability analysis by Office of Technology Transfer staff

and/or patent attorneys. Since patent attorney fees are high, complete information is highly desired.)

2.2 KINDLY ATTACH ALL NECESSARY ILLUSTRATIONS USED IN DESCRIBING THE INVENTION (If unpublished manuscripts or published articles are enclosed, please refer to the illustrations in the articles. Please include all nucleotide and deduced polypeptide sequences, chemical structures and machine designs that describe the

invention.)

2.3 LABORATORY RECORDS (Please indicate the physical location and reference numbers of applicable laboratory records. There is no need to attach

the records.)


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Section 3: MARKET INFORMATION

The following questions are meant to help you consider the best path for your technology to market. Well-reasoned answers

will increase the market's interest in your technology while preparing you to address potential investors. These questions are intentionally thought provoking, so please feel free to reach out to the technology transfer office for a discussion.

3.1 WHO WILL BENEFIT FROM YOUR INVENTION? (What problem would it solve or what presently unknown benefit might it deliver and for whom? What market segments would be first, second, and third priorities and why?)

3.2 HOW WILL THE BENEFITS BE DELIVERED? (How would the product or service be marketed to the end user? Would it be purchased or rented via a service agreement? Are there companies that might license the invention? If so, please list these companies/contacts and be sure to note whether you spoken with any of them.)

3.3 HOW WILL THE BENEFITS BE PAID FOR? (Does the customer buy your invention directly or is it supplied by an employer, insurer, or some other third party? If a

third party, why would the third party pay for it?)

3.4 WHY IS YOUR INVENTION SUBSTANTIALLY BETTER THAN THAT OF AN EXISTING OR POTENTIAL COMPETITOR?

(What is the current competitive "gold standard”? Who are your competitors? Why would their products or services be abandoned in favor of your invention?)


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3.5 HOW WILL YOU BRING YOUR INVENTION TO MARKET AND HOW MUCH TIME WILL IT TAKE AND WHAT WILL IT COST?

(If it is to be licensed, what will be needed to complete that work and license? If you need to establish a separate company, how do you plan on doing that? What would it cost? What role would you anticipate playing in the new company?)

LENGTH OF TIME: ESTIMATED COST: $

3.6 ARE YOU AWARE OF ANY PUBLICATIONS OR PATENTS THAT MIGHT OVERLAP WITH OR CHALLENGE YOUR INVENTION? Yes No

(If yes, please list your findings and cite sources.)

3.7 HAVE YOU IDENTIFIED A DEFINITIVE LICENSEE OR SPONSOR? Yes No (If yes, please list any leads you may have that could be contacted.)

COMPANY ADDRESS CONTACT TELEPHONE/EMAIL


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Section 4: SIGNATURES (All Inventors must sign)

Name, title, signature and percent contribution of each person who made an INTELLECTUAL CONTRIBUTION to the invention

described in this disclosure. According to the Patent and Copyright policy of the University of Miami the proceeds received by the University, after costs are recovered, will be distributed among the inventor(s), and other entities within the University. Respective intellectual contributions of the co-inventors outside the University of Miami should also be mentioned with their

primary department and institutional affiliation. Co-inventors who are not University of Miami employees must complete section 6, to provide their residential addresses and social security numbers; the information is used later if patent applications are filed.

I (we) hereby declare that all statements made in this invention disclosure are true and accurate to the best of my (our)

knowledge.

And I (we) herby further declare that no sections of this invention disclosure form were deleted, added or changed.

Inventor's Signature Date

% Name Interest

PRIMARY Department/Institute or Center Affiliation

SECONDARY Department/Institute or Center Affiliation


% Name Interest




% Name Interest




% Name Interest




% Name Interest




% Name Interest



REQUIRED SIGNATURES OF TWO WITNESSES WHO UNDERSTAND THE TECHNICAL ASPECTS OF THE INVENTION: I declare my understanding of the disclosed technology:

Witness Signature Date

Name

Witness Signature Date

Name


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Section 5: ASSIGNMENT (All University of Miami Inventors Must Sign)

Consistent with my (our) obligations set out in the University of Miami Patent and Copyright Policy, in the University of Miami

Faculty Manual, the Policies and Procedures Manual, the Graduate Studies Bulletin, and the Undergraduate Studies Bulletin, I (we) hereby execute this Assignment and "other documents as may be required" to comply with the provisions of the publications mentioned above. Additional assignment documentation may be required at the time of patenting. I (we) also

agree to cooperate with the University of Miami Office of Technology Transfer in the protection and commercialization of this invention.

I (we) hereby, assign and convey to the UNIVERSITY OF MIAMI, its successors and assign, the full and exclusive right, the title and interest in and to this invention as described in this invention disclosure and to the patents that may issue thereon

for the full benefit and behalf of said UNIVERSITY OF MIAMI.


Name

Home Address

Country of Citizenship


Name

Home Address



Name

Home Address



Name

Home Address



Name

Home Address



Name

Home Address



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Section 6: ADDRESSES OF CO-INVENTORS EMPLOYED BY OTHER INSTITUTIONS

Name

Email

Home Address


Affiliated Institution

Name

Email

Home Address



Name

Email

Home Address



Name

Email

Home Address



Name

Email

Home Address



Name

Email

Home Address



Thank you for submitting the invention disclosure to the Office of Technology Transfer. A manager will be assigned to this technology and will contact you shortly following a review your submission. If you have any questions or additional

findings pertaining to the submission, please contact your assigned manager. If there is an urgent issue, please contact the office at 305-243-5689.

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