Invention Disclosure Form
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1 Invention Disclosure Form For Internal Use Only Invention Number: Contact/Submission Info Please address all questions and return an electronic copy of the completed form to: Anthony Sutton, Senior Invention Administrator P: (617) F: (617) (While filing form online, please have insert key inactive) When complete, please save and hit Submit button to directly for submission. 1. TITLE OF INVENTION 2. CATEGORY OF INVENTION Patent Material Software Copyright Trademark 3. DESCRIPTION OF THE INVENTION Describe the Invention to the extent known at this time. A. Key concepts of Invention, including nature, stage, purpose of operation of the invention including technical characteristics: (In addition, please attach manuscript, presentation, poster, or other documents, including any public disclosure documents) B. Distinguishing novel features of Invention: C. Envisioned commercial products or processes:
2 4. PUBLIC DISCLOSURE OR USE Public disclosure or use of an invention prior to filing a patent application will either limit or eliminate patent rights, dependent upon the extent of what was disclosed. A. Any past or future manuscript submission of Invention? Yes, No Expected date of online or paper publication B. Any past or future abstract, poster or talk of Invention? Yes, No C. Any past or future journal publications (online and print)? Yes, No D. Any past or future disclosures outside hospital of Invention? Yes, Entity: No E. Any other past or future public disclosures? Type: Yes, Entity: No F. Has Invention been used, tested or offered for sale? Yes, No 5. SUPPORT FOR INVENTION (Indicate ALL types of support, e.g., material, software, equipment, money or other) Federal (Agency and Grant/Contract No.) PI: No Federal Funding Industry ; List type of support (material or money) Agreement No. List other type of support or collaboration with industry (e.g., on-going clinical trials): Academic Collaborator List type of support (material and/or money or other): Agreement No. Foundation PI: Other (e.g., Shriners, CIMIT, HHMI, HSCI, VA) If Shriners, indicate % attributable to Shriners: % Other Funds (Gifts, Departmental, Sundry, Broad, etc)
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