CONFIDENTIAL
Academic Affairs
Office of Research &
Graduate Studies
INVENTION DISCLOSURE FORM
P
ursuant to Florida Gulf Coast University (FGCU) Intellectual Property Policy (Policy No. 2.002), “The University is
implementing this authority through this Intellectual Property Policy, which requires that all Florida Gulf Coast University
employees disclose certain works and inventions that are developed or discovered while affiliated with the University.”
Th
is form is used to disclose generally patentable materials of an invention. All questions included in this disclosure
form are important. It is required that the leading inventor provide information to all questions with adequate details.
You may provide attachments as necessary.
I
f you have any questions, please contact the Office of Research & Graduate Studies (ORGS) at research@fgcu.edu
.
Please forward the completed form to research@fgcu.edu.
A. DE
SCRIPTION OF INVENTION
1. Title of the Invention
2. Description of the Invention (< 250 words)
3. Does your invention have any practical applications in solving practical, real-world
pr
oblems?
NO
YES; please specify.
4. Will your invention result in any commercializable product(s)?
NO
YES; please answer the following questions:
4a. Specify/describe the product(s).
4b. Provide estimated timeline to commercialize the product(s).
2
4c. Have you developed and tested on working prototype(s) of your product(s)?
NO
YES; please provide details.
4d. Do you have any potential commercialization partner(s) in contact, or in mind?
NO
YES; please specify (e.g., Hertz).
5. Please provide an estimated economic value of your invention if commercialized:
< $50,000
$50,000 $100,000
$100,000 $500,000
$500,000$1,000,000
> $1,000,000
6. Are you aware of any related inventions and/or developments by others?
NO
YES; Please provide information/data as to what are the same, or similar, inventions (e.g.,
technologies, systems, devices) currently available.
7. Why is your invention more advantageous than, or superior to, currently available
inventions?
8. What are the novelties and/or unusual features that differentiate your invention from others?
9. What is the potential impact of your invention (select one only)?
Provide new findings only (e.g., theory, methodology, technology, design, formula)
Marginal improvement
Significant improvement
Revolutionary
Create new field(s)
Others (please specify)
10. Additional comments
3
B. PUBLICATIONS, PUBLIC USE AND SALE
1. Has the invention been disclosed to the public in the past 12 months?
NO
YES; please specify the type of disclosure (e.g., conference presentation) and disclosure
date.
2. Has there been any public use or sale of products embodying the invention?
NO
YES; please provide details.
C. SPONSORSHIP
1. Please specify if the invention is developed/evolved from a sponsored project, program,
grant, contract, etc.
NO; skip to the next section.
YES; please answer the following questions:
3a. Name(s) of sponsoring agency:
3b. Grant/Contract No.:
3c. Has the invention been disclosed to the sponsoring agency or others?
NO
YES; please provide details.
2. Did you, or any other co-inventors, use or include any already patented materials or
processes belonging to others in this Invention Disclosure Form?
NO
YES; please provide details.
4
D. EVALUATORS/REVIEWERS
Please provide contact information of at least three individuals, including one from outside
FGCU, other than inventors of this invention with technical or economic knowledge in the field of
the proposed invention. Evaluators/reviewers could be asked, under confidentiality undertakings,
to evaluate or review the proposed invention. The following contact information must be provided:
Evaluator/Reviewer 1
Last name, First name:
Institution/Organization:
Department/Division/Unit:
Email:
Phone/Cell#:
Evaluator/Reviewer 2
Last name, First name:
Institution/Organization:
Department/Division/Unit:
Email:
Phone/Cell#:
5
Evaluator/Reviewer 3
Last name, First name:
Institution/Organization:
Department/Division/Unit:
Email:
Phone/Cell#:
E. SIGNATURES
Please list names and contact information of all inventors to be included, for example, in the
patent application.
Lead Inventor:
Last Name of leading inventor:
First Name of leading inventor:
Current business/mailing address:
Permanent mailing address:
Email:
Phone/Cell#:
Signature: Date:
click to sign
signature
click to edit
6
Co-Inventor:
Last name of co-inventor:
First name of co-inventor:
Current business/mailing address:
Permanent mailing address:
Email:
Phone/Cell#:
Signature: Date:
* Add additional co-inventors in the same format with signatures.
F. ATTACHMENTS
click to sign
signature
click to edit
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