Invention Disclosure Report

Please read this section prior to completing this form The Office of Technology Development (OTD) reviews all invention disclosure forms from members of the HSS community. Where appropriate, the OTD endeavors to license HSS inventions to industry for further development and commercialization. The purpose of this form is to notify the OTD of your potential invention and serves to establish a legal record of the date of conception of the invention.

If you have any questions about completing this document, contact the OTD’s Director—Donna Rounds, PhD (RoundsD@hss.edu or 212-774-7165). Please distribute copies to all individuals who worked on this invention as identified in the contributor information section.

Please check the box if you plan to publish or publicly present any aspect of the invention within the next 15 days.

1. Title of Invention *This question is required.

2. Date the invention was conceived *This question is required.

calendar

3. Is this invention related to any inventions you have previously disclosed? *This question is required.If yes, please state the title of the related invention

Please enter an 'other' value for this selection.

4. Description of Invention Please provide a brief abstract of the invention, including the background of the problem being solved, features of the invention and the stage of the invention.

5. Public Disclosure *This question is required.

Space Cell	Yes	No
A. Have you discussed this invention with anyone?
B. Any past or future disclosure to a journal, abstract, poster or talk about the invention?
C. Has the invention been used, tested or offered for sale?

6. Support for Invention (optional)Please include all outside agencies, foundations, organizations, or companies and the applicable contract or grant number(s) that provided funding to any contributor for the research that led to the invention. (If there is no funding or sponsorship, then state None.)

Space Cell	Agency	Grant/Contract No.	PI Name	Value	Time Period
1	Agency	Grant/Contract No.	PI Name	Value	Time Period
2	Agency	Grant/Contract No.	PI Name	Value	Time Period
3	Agency	Grant/Contract No.	PI Name	Value	Time Period
4	Agency	Grant/Contract No.	PI Name	Value	Time Period
5	Agency	Grant/Contract No.	PI Name	Value	Time Period

7. Materials for Invention (optional)Did you use any biological materials provided by a third party in the course or performance of this research?

8. Commercial PossibilitiesPlease list potential licensees or suggested companies to be approached. If the invention has been disclosed to industry representatives, please provide details. (If there is no information, then state None.)

Space Cell	Company	Contact Person	Email Address	Telephone
1	Company	Contact Person	Email Address	Telephone
2	Company	Contact Person	Email Address	Telephone
3	Company	Contact Person	Email Address	Telephone
4	Company	Contact Person	Email Address	Telephone
5	Company	Contact Person	Email Address	Telephone

9. Please list the names of all contributors to this invention.

Space Cell	Name	Email	Phone
1	Name	Email	Phone
2	Name	Email	Phone
3	Name	Email	Phone
4	Name	Email	Phone
5	Name	Email	Phone

10. Additional Information (optional) Please provide any additional information that may be relevant to the invention (e.g. manuscript(s), presentation(s), poster(s) or other documents pertaining to this invention)

Invention Disclosure Report

Section I: Invention Summary