ࡱ>  bjbj ||  44444HHH8TtH4d,4```T4^4`4`4`4`4`4`4$o7!:p44444``44!!!4`4`^4!^4!!1|2`: ,1J44041::$228:42|!44!4: : INVENTION DISCLOSURE FORM This form is an important legal document and should be filled out with care. Please be as inclusive as possible and attach any additional documents you feel will assist in the assessment of the technology. If you have any questions, please contact the Technology Transfer Office at (216) 687-5108. Please send a hard copy of this form signed by all the inventors to: Technology Transfer Office 91Ʒ 2258 Euclid Ave., Parker Hannifin Hall, Room 214 Cleveland, Ohio 44115 In addition, please email this form to: j.kraszewski@csuohio.edu Date Received by TTO: ___________  TITLE OF INVENTION INVENTOR(S) List all inventors, inside and outside 91Ʒ, that may have contributed to this invention. NAME (first, middle initial, last)SCHOOLDEPT. OF APPOINTMENTPOSITION  FUNDING SOURCES AND RESEARCH SPONSORS All Funding Sources and Grant Numbers must be correct. Please list all digits in funding sources and grant numbers, including zeros. SOURCE OF FUNDSNAME AND GRANT NO.Federal Agencies: Foundation: Corporate: 91Ʒ Funds, Facilities: Other: MARKETING ABSTRACT: ABSTRACT (write a short paragraph, in 200 words or less, describing the unmet need and a lay summary of the technology) Applications (describe all potential applications of the technology in bullet points) Advantages (how does it improve upon existing technologies? What differentiates it from other solutions to the problem it addresses? Please write in bullet point format)  DESCRIPTION OF INVENTION: Brief Summary of Technology (Include any relevant manuscripts, drawings, sketches, and/or publications) Technical Description (Attach any relevant figures necessary for an understanding of the invention. Provide enough detail so that someone skilled in your field could replicate the invention)  DISCLOSURESPlease list all relevant disclosures, both past and anticipated, and their dates below. If no disclosures have been made or are expected to be made, type NONE in respective fields. LOCATION DATE Journal ArticleConference AbstractOral Presentation Poster PresentationDisclosure to IndustryGrant ProposalOther DATE AND PLACE WHERE DISCOVERY WAS MADEWhen was the idea conceived?Where and how was it documented? When was the idea reduced to practice?  PRIOR ARTList known related patents and printed publications: List known researchers who are active in this field:  COMMERCIALIZATIONWhat commercial problem does the invention solve? What is the unmet need? Who are potential licensees? (list companies with any known contacts or highlight relevant industries): What commercially available products (if any) address the same problem, at least in part (list company and product)Would you like to develop this invention further with corporate research support? FORMCHECKBOX  YES  FORMCHECKBOX  NOWould you be interested in participating in campus-based programs for commercialization research or business planning for your invention? FORMCHECKBOX  YES  FORMCHECKBOX  NOIs there a primary inventor contact? If so, then whom?  FORMCHECKBOX  YES  FORMCHECKBOX  NO  MATERIALS ASSOCIATED WITH INVENTIONDid this invention use any Materials which were obtained with a Materials Transfer Agreement from a company or another institution? FORMCHECKBOX  YES  FORMCHECKBOX  NOIf yes, please list the name of the company or institution I certify that all of the information provided herein is complete and accurate to the best of my knowledge. This disclosure is submitted pursuant to the 91Ʒ Patent Policy (3344-17-01 and 3344-17-02) and is subject to all the terms of that Policy. I have reviewed and understand the University Patent Policy. If this invention is accepted by the Technology Transfer Office at 91Ʒ, I hereby agree to cooperate fully with the University in the protection and commercialization of this invention and understand that any revenues derived from this invention will be distributed according to University policy.Please insert your first name, middle initial and last name as it will appear on any patent applications and related documentation. INVENTOR(S)NAME: UNIVERSITY PHONE: CELL PHONE: EMAIL: HOME ADDRESS: CITIZENSHIP: 91Ʒ ID: SIGNATURE:  Please insert your first name, middle initial and last name as it will appear on any patent applications and related documentation. INVENTOR(S)NAME: UNIVERSITY PHONE: CELL PHONE: EMAIL: HOME ADDRESS: CITIZENSHIP: 91Ʒ ID: SIGNATURE:  Please insert your first name, middle initial and last name as it will appear on any patent applications and related documentation. INVENTOR(S)NAME: UNIVERSITY PHONE: CELL PHONE: EMAIL: HOME ADDRESS: CITIZENSHIP: 91Ʒ ID: SIGNATURE:  Please insert your first name, middle initial and last name as it will appear on any patent applications and related documentation. INVENTOR(S)NAME: UNIVERSITY PHONE: CELL PHONE: EMAIL: HOME ADDRESS: CITIZENSHIP: 91Ʒ ID: SIGNATURE:  Please insert your first name, middle initial and last name as it will appear on any patent applications and related documentation. 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