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UNI VERSITY OF DAYTON TECHNOLOGY DISCLOSURE FORM INVENTIONS (University of Dayton)

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Page 1 of 4
Disclosure ID __________________
Log-In-Date __________________
OFFICE USE ONLY 3/10/15
UNI
VERSITY OF DAYTON
TECHNOLOGY DISCLOSURE FORM – INVENTIONS
1. Descriptive Title of Invention
2. Inventor(s)
Name (typed) Name (typed)
Employer Employer
email email
Business Phone No. Business Phone No.
Home Address Home Address
Signature/
Date
Signature/
Date
Name (typed)
Name (typed)
Employer Employer
email
email
Business Phone No. Business Phone No.
Home Address
Home Address
Signature/
Date
Signature/
Date
Name (typed)
Name (typed)
Employer Employer
email
email
Business Phone No. Business Phone No.
Home Address
Home Address
Signature/
Date
Signature/
Date
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Page 2 of 4
3. Witnesses: The disclosure shall be signed by two witnesses who are not inventors of any part of this
invention.
Name (typed) Name (typed)
Signature
Signature
Date
Date
4. Approval: The disclosure shall be signed by the Research Institute division head and/or the academic
department chair as applicable.
Name (typed) Name (typed)
Signature
Signature
Date
Date
5. First Public Disclosure. Identify the names, places, and dates associated with the first disclosure of
enabling details of the invention to anyone outside the University without the benefit of a formal
confidentiality agreement. Identify why type of disclosure took place. Attach copies of any
publications. If you are not sure whether public disclosure has been made, give the details of all
external communication concerning the invention. If there has been no outside disclosure, so
indicate and include any planned date of disclosure.
*Important* Once submitted, any disclosure of the technology must be reported to the office to
maintain conformance to patent time limits surrounding the technology.
Oral presentation to a scientific meeting or an informal group. Date
Circulation of an abstract of a talk. Date
Publication of a journal article or news story. Date
Delivery and distribution of a contract report. Date
Planned Disclosure Date:
NO PUBLIC DISCLOSURE AT THIS TIME
6. A) EXTERNAL FUNDING
Was the work leading to the invention performed (in whole or in part) on an externally sponsored
program? Yes No
Sponsoring Agency/Firm
Account Number(s)
(required)
Contract Number(s)
(required)
B) INTERNAL FUNDING
Was the work leading to the invention performed (in whole or in part) funded at least partially with
internal fund? Yes No
Sponsor/Dept/Award Name:
Account Number(s)
✔
✔
Page 3 of 4
7. Date and circumstances of first verifiable record of the invention:
8. Date and description of other written records of the invention predating this disclosure:
9. Is there a laboratory notebook record of this invention? Yes No
Notebook number or other identification
Page numbers
10. Has the invention been demonstrated experimentally? Yes No
Date
Description:
11. Sale of Produc
t. Has a purchase order been accepted for sale of the result of the invention in any
form? Yes No
If YES, please provide pertinent details
12. Samples. Have samples of the invention been given to anyone outside the University for evaluation
(including sponsors)? Yes No
Please provide pertinent details:
13. What do you see as the commercial value of the invention? What is the market and how large is it?
14. List the names of companies that might be interested in licensing the invention. If you have contacts
with these companies please list those as well.
✔
✔
✔
Page 4 of 4
15. Attach to this form a Nonconfidential Abstract of the invention addressing the items listed below:
(a) Description. Provide a brief general description that communicates the essence of the invention without
disclosing pertinent technical details.
(b) Application. Intended use of the invention, especially for commercial purposes. Be specific.
(c) Advantages. What is new and useful about the invention? Why is it better than the prior art?
(d) Current State of Development. Is the invention a concept only, fully developed and ready to license, or
somewhere in between? Give some idea of how much development work would be needed to
commercialize the invention.
16. Prepare the Detailed Description so an individual reasonably skilled in the art would readily
recognize what is new, different, useful, and non-obvious about the invention. Try to communicate
the central essence of the invention. Use photographs, sketches, and graphs as necessary. Include the
following elements in the description.
(a) Intent. Briefly identify the problem and/or need addressed by the invention.
(b) Applicability. Describe the invention's general areas of application and specific uses.
(c) Function. Describe in detail the pertinent features of the invention with emphasis on (1) novelty,
(2) advantages, (3) disadvantages and limitations, and (4) prior related inventions.
(e) Inventors' Roles. If more than one inventor contributed to the invention, describe the individual roles and
contributions of each inventor to either the concept or its successful reduction to practice.
Submit completed disclosure form to:
THE UNIVERSITY OF DAYTON
Office of Technology Partnerships
300 College Park
Dayton, OH 45469-0102
Telephone 937-229-3469
Fax 937-229-3873
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Completed 29 August 2020

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