ࡱ> $'!"#O 4bjbjee I(eec,K8?4sU[^"L[%q%q%q%&@&$ 'ZZZZZZZ$]i`HZ'&&''Zq%q%4[/+/+/+'Rq%q%Z/+'Z/+/+MRq%0B\/o'PHZ%[0U[Q`i(``RR`S@''/+'''''ZZ)f'''U[''''`''''''''' :  Invention Disclosure Form  No. 202_ -____________________ Please submit disclosures to: The Office of Research and Sponsored Programs Attn: AVP for Research and Sponsored Programs The disclosure will be reviewed for completeness and when complete will be moved forward to the Office of the Provost and Vice President Academic Affairs for additional review and determination. Keep the following in mind while completing this form. The criteria for a U.S. Patent are novelty, utility, and non-obviousness. Novelty: An invention is novel if nothing identical previously existed. How does the invention differ from what already exists? In what ways might it not be unique? Utility: Who might find the invention useful, and why? What companies might be interested in making or selling it, and why? Is there other technology that currently provides similar utility--If so, what is the unique advantage of your invention? Non-obviousness: Non- obviousness measures the degree to which an invention could not have been anticipated from the totality of previous knowledge. At the time it was conceived, why might the invention not have been obvious to other people reasonably skilled in the field? Are there ways in which it might be part of an evolutionary trend? Type of Invention Inventions include new processes, products, apparatus, and compositions of matter, living organisms - or improvements to existing technology in those categories  FORMCHECKBOX Device  FORMCHECKBOX Software  FORMCHECKBOX Other (Choose one and then describe below) Title Short interesting descriptive title Abstract Summary invention (2-3 sentences or short paragraph) Criteria Describe what you have identified as novel or unique, the utility, and non-obviousness Key Benefits to the World Describe the key benefits or advantages of the invention Requirements Biological Material Does this disclosure include biological material?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Did the research require a Materials Transfer Agreement (MTA)? If yes, submit a copy of the MTA with this Invention Disclosure Form.  FORMCHECKBOX  Yes  FORMCHECKBOX  No Human Subjects Did the research leading to the invention being disclosed require an IRB Protocol approval? If yes, submit a copy of the IRB Protocol and Approval Letter with this Invention Disclosure form  FORMCHECKBOX  Yes  FORMCHECKBOX  No Animal Subjects Did the research leading to the invention being disclosed require IACUC approval? If yes, submit a copy of the IRB Protocol and Approval Letter with this Invention Disclosure form.  FORMCHECKBOX  Yes  FORMCHECKBOX  No Software Did this research include software development associated with the invention?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Describe the software if not already described above: Other: Describe any potential Conflicts of Interest, Resource, or Legal Issues that may impact patent rights. Funding and Resources An invention is considered to have partial institutional support if the institution incurs resource costs associated with the invention. Institutional support includes those costs that would not have been incurred by the institution in the absence of the development of the invention or discovery, as well as those other costs associated with the significant use of Cal State East Bay or ñ auxiliary equipment, supplies, facilities, employee time, or other institutional resources. Where not applicable or where there were none, write N/A or None. Describe funding source(s) related to this invention and research leading to the invention. Funding Entity Award/Contract Number *Type of Funding  FORMCHECKBOX Federal  FORMCHECKBOX Industry  FORMCHECKBOX University  FORMCHECKBOX Other (explain):  FORMCHECKBOX Federal  FORMCHECKBOX Industry  FORMCHECKBOX University  FORMCHECKBOX Other (explain):  FORMCHECKBOX Federal  FORMCHECKBOX Industry  FORMCHECKBOX University  FORMCHECKBOX Other (explain):  FORMCHECKBOX Federal  FORMCHECKBOX Industry  FORMCHECKBOX University  FORMCHECKBOX Other (explain):  FORMCHECKBOX Federal  FORMCHECKBOX Industry  FORMCHECKBOX University  FORMCHECKBOX Other (explain): *Please attach a copy of the award notification for each funded project. Describe other resources provided related to this invention and research leading to the invention. List Cal State East Bay resources or Other CSU facilities or Resources Used List Non-CSU resources used by employee for this patent or research leading up to this patent Non-University Consulting Agreements Do you or did you or any other member of the inventive group work on this project under a non-University consulting agreement?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If so, does the Consulting Agreement discuss inventions made during the project? If so, attach a copy if possible.  FORMCHECKBOX  Yes  FORMCHECKBOX  No Centers and Institutes Is this invention or research that led to the invention affiliated with a CSU Center or Institute? If Yes, list the name of the center or institute. ________________________  FORMCHECKBOX  Yes  FORMCHECKBOX  No Public Disclosure Disclosures - Describe prior or anticipated public disclosures of invention or research that led to the invention Title Type of Disclosure Date of Initial Disclosure Published? Yes or No? (if yes, list all journal citations & reprints)  FORMCHECKBOX Abstract(s)  FORMCHECKBOX Seminar(s)  FORMCHECKBOX Publication(s)  FORMCHECKBOX Presentation(s)  FORMCHECKBOX Other _________  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX Abstract(s)  FORMCHECKBOX Seminar(s)  FORMCHECKBOX Publication(s)  FORMCHECKBOX Presentation(s)  FORMCHECKBOX Other _________  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX Abstract(s)  FORMCHECKBOX Seminar(s)  FORMCHECKBOX Publication(s)  FORMCHECKBOX Presentation(s)  FORMCHECKBOX Other _________  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX Abstract(s)  FORMCHECKBOX Seminar(s)  FORMCHECKBOX Publication(s)  FORMCHECKBOX Presentation(s)  FORMCHECKBOX Other _________  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX No Prior or Planned Public Disclosures at This Time 4. Inventor(s) Contact Information In box 1 list the name and contact information of the ñ employee making the invention disclosure, then list collaborators in subsequent boxes along with their percentage of contribution to the invention. Name of Cal State East Bay Employee: ____________________________________________________ Email Address________________________________________ Job Title_____________________________________________ Main Department:_____________________________________ Deans Name _________________________________________ Department Chairs Name_______________________________ Percentage Contribution:____% Collaborators Collaborator 1 Name: ____________________________________________________ Email Address:________________________________________ Job Title_____________________________________________ If ñ, Main Department:_____________________________ If Non ñ, provide company affiliation, if any: ____________________________________________________ Email Address:________________________________________ Percentage Contribution:____% Collaborator 2 Name: ____________________________________________________ Email Address:________________________________________ Job Title_____________________________________________ If ñ, Main Department:_____________________________ If Non ñ, provide company affiliation, if any: ____________________________________________________ Email Address:________________________________________ Percentage Contribution:____% Add additional Collaborators as needed. NOTE: Combined Inventor contributions must TOTAL 100%. 5. Commercialization List any Companies that may be Interested in Your Research Company 1: Company 2: Commercial Products - List any commercial products or services you believe could benefit from this invention or research that led to the invention. Are you currently seeking additional funding for this invention or research? If yes, please list the potential source(s) of funding:  FORMCHECKBOX  Yes  FORMCHECKBOX  No 6. Submission Please submit disclosures to: Office of Research and Sponsored Programs (ORSP) Attn: AVP For Research and Sponsored Programs 7. Disclosure and Review Disclosure: By signing, I (We) understand that in accordance with the Cal State East Bay Patent Policy/Intellectual Property Policy, all inventions which I (we) conceive or develop while employed by ñ shall be disclosed for examination by the university to determine the extent of the use of university resources to further determine rights and equities therein. I (We) hereby agree to promptly furnish the university with any additional information necessary to this determination. When required I (we) will fully cooperate with the university or its designee in securing appropriate protection for the intellectual property embodied in this invention. _________________________________ _____________________ __________ Cal State East Bay Employee 1 Signature Print Last Name Disclosure Date (Employee disclosing invention) _________________________________ _____________________ __________ Cal State East Bay Employee 2 Signature Print Last Name Disclosure Date (Employee disclosing invention) All employees disclosing the invention should be listed above In Section 4, inventor(s) Contact Information. Add Signatures as needed. Review: The AVP for Research and Sponsored Programs or their designee will review for completeness. The Provost or their designee will review for determination of ownership, and will provide a letter of determination with an intent to provide a release, assign rights, or enter into additional agreements as may be necessary. _________________________________ _____________________ __________ AVP, ORSP or Designee Print Last Name Date Reviewed _________________________________ _____________________ __________ Provost and Vice President for Academic Affairs Print Last Name Date Reviewed      Page PAGE 4 Final June 2021  $'*,-ACDGJʹ|mamPA1hT2hpp5CJOJQJ^JhYhppCJOJQJ^J hi\hd CJOJQJ^JaJhJxCJOJQJ^Jhi\hppCJOJQJ^Jh>4CJOJQJ^Jhi\hCJOJQJ^J hi\hCJOJQJ^JaJ hi\hCJ OJQJ^JaJ hi\h<CJ OJQJ^JaJ hi\hI@CJ OJQJ^JaJ hi\hCJOJQJ^J)jhi\hppCJ OJQJU^JaJ BCD[YjkdG$$IflF *  t>+    44 laytd $K$If]Ka$gdpp $$Ifa$gd[ $Ifgd[ `$If^`gd[DGi  [ -   !1Q$If^1`QgdY$ !1Q$If^1`Qa$gd| !1Q$If^1`Qgd>4$ !1Q$If^1`Qa$gdppJXYhlzE i  & - w z      X [ w 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