Refer to University Copyright Policy #84 (http://www.wcu.edu/chancellor/index/universitypolicy/policy84.htm) for current information.
Appendix A
CONFIDENTIAL
Western Carolina University
Report of Invention
1. Inventor(s): (List name, professional affiliation, mailing address, telephone. Underline name of person to contact for more information.)
Pursuant to the Patent Policy and Procedures of Western Carolina University, I/we hereby disclose details about the following invention:
2. Title of Invention:
3. Date of Invention: (Indicate actual or approximate dates.)
Earliest conception:
Experimentation period:
Reduction to practice:
4. Brief Description of Invention: (Identify whether invention is a new process, composition of matter, a device, one or more products, a new use for or an improvement to an existing product or process. Include nature, purpose, operation and basic characteristics of the invention.)
(Use additional sheets if necessary and attach descriptive materials that may promote a better understanding of the invention.)
5. Publication:
(a) Indicate details of any full or partial disclosure of this invention by any of the inventors named in paragraph 1. The means may have been one or more of the following: manuscript, article, report, grant application, thesis, abstract, demonstration, sales catalog, news release, internal memorandum, or oral presentation. Specify date and attach copies of written disclosures insofar as possible.
(b) Describe in detail any plans for disclosure of this invention in the near future. (This may include submission of a manuscript, a formal publication, oral presentation, a showing, offer of samples, or a sale.)
6. Sponsorship for Work Leading to the Invention:
Sponsor(s):
Contract or grant number:
Funding period:
Principal Investigator:
Attach relevant patent sections from the funding instrument or sponsor’s policy manual if available.
7. Prospects for Commercialization:
(a) Indicate any apparent commercial interest. Please name companies and specific persons if possible.
(b) List names of other qualified firms with your comments, if any.
8. Signature(s) of Inventor(s):
________________________________________________ ________________________ Signature date
________________________________________________ ________________________ Signature date
________________________________________________ ________________________ Signature date
9. Signature of Person Witnessing This Disclosure:
________________________________________________ ________________________ Signature date
________________________________________________
Typed name and title
10.Signature of Department Chair(s) Affected by This Disclosure:
________________________________________________ ________________________ Signature date
________________________________________________
Typed name and title
________________________________________________ ________________________ Signature date
________________________________________________
Typed name and title
Please send this form to the university’s legal counsel.
11.Legal Counsel:
_______________________________________________ __________________________________________ Signature Date Disclosure received in Office of the Legal Counsel
_______________________________________________ ________________________
Typed name and title Telephone