ࡱ> Q bjbjXX :2e2ew}" " ggggg{{{8lt{73p42222222$5]82gu"2gg2;!;!;!Fgg2;!2;!;!.r/u7`^.23073.9;9(r/,/9g/;!22S 739" -:  Boston College Invention Disclosure Form Per the Boston College Intellectual Property Policy, an invention is a new or useful process or discovery, art, method, technique, product, machine, device manufacture, software, composition of matter, or improvement thereof which should promptly be disclosed to the Office of Technology Transfer and Licensing (OTTL) for evaluation. OTTLs mission is to empower Boston College inventors and authors by protecting their inventions and supporting their wide dissemination, commercially or otherwise. Completed disclosures will be evaluated for patentability and commercial potential, when sent to: Jason Wen, DirectorOffice for Technology Transfer and LicensingEmail:  HYPERLINK "mailto:Jason.wen@bc.edu" Jason.wen@bc.edu 1. Title of invention:  2. Please list all individuals you believe to be inventor(s), attaching additional tables as required: NameInstitutionPositionDepartmentPhone/E-Mail Is Federal Employee?(Y/N)Contribution Percentage (total 100%) 3. Indicate all sources of funding for the invention, including internal or funding received from government agencies, nonprofit organizations or commercial entities: Sponsor(s)Contract/Grant No(s).Period of FundingPrincipal Investigator 4. Use of Boston College and External Resources: When and where was the invention first conceived at ֱ? In generating the invention, did you use any confidential information, materials, equipment, software, facilities, or other items obtained from entities other than Boston College or individuals other than your co-inventors?xCheck as May ApplyYesNoIf so, please give the name(s) of these sources and describe the nature of the item(s): Is there an agreement in place covering the provision of the item(s) to you? If so, please describe. 5. External Disclosure Information: xCheckPlease Provide Dates, Circumstances, Location, etc.Has the invention been described, in whole or in part, in any conferences, or any printed or online publication? YesNoHas a manuscript describing the invention, in whole or in part, been submitted for publication? If so, when?YesNoIf a manuscript has been submitted, has it been accepted for publication? If so, provide the name of journal and anticipated date of publication in print or online.YesNoHas the invention been described in any application for external funding? If so, provide the name of the external organization and the date of application.YesNoHas the invention been disclosed in a public setting such as a poster session, conference, or seminar? If so, when? If not, are any such disclosures scheduled to occur?YesNoHas the invention been disclosed in a private setting, such as a conversation with a company or with colleagues at another institution? If so, please describe.YesNo 6. Keywords and Related Publications: Please list keywords and pertinent publications (by you or by other researchers) which are related to the invention or to this area of research, to support prior art review and market analysis.  Technical Description. Please include a detailed technical description of the invention, in addition to any drawings, photos, or other figures that help describe what is novel, useful, and non-obvious about the invention. A draft manuscript is ideal. Is the invention an improvement to, or a new use of, an existing product or process, and if so, what are its novel features? What are its advantages?  8. What uses do you foresee for this invention? (please feel free to speculate, and be creative!) Are there specific problems, or needs, addressed by the invention? If so, what is currently being used to address these, and how is the invention advantageous over these existing solutions?  9. Are you aware of any companies which you believe are conducting similar research, or which could take an interest in licensing this invention? If so, please list them and note whether you have an existing relationship. 10. Inventors signatures (attach additional tables as required): By signing, you agree that: All information provided herein is true and complete to the best of my knowledge. I will do everything reasonably requested by the Boston College Office of Technology Transfer and Licensing to assist in the evaluation, protection and possible commercialization of this invention. If I am an employee or student of, or fellow at, Boston College, I hereby assign all right, title and interest to the invention described herein to Boston College. Print or Type Name:Print or Type Name:Signature and Date:Signature and Date:Home Address:Home Address:Country of Citizenship:Country of Citizenship:Personal Email:Personal Email:Print or Type Name:Print or Type Name:Signature and Date:Signature and Date:Home Address:Home Address:Country of Citizenship:Country of Citizenship:Personal Email:Personal Email: Please note: if your home address changes, it is your responsibility to notify the Boston College Office of Technology Transfer and Licensing, and to provide your current contact information. If not, this could not only delay actions relating to the protection and commercialization, but could also affect your receipt of any royalty checks which may result from the licensing of this invention.      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