Web Form Builder Disclosure Form

Rensselaer Polytechnic Institute

Invention Disclosure Form

Disclosure Date

Today’s Date

Please indicate the number of Contributors

LEAD CONTRIBUTOR

RPI Non-RPI

Last Name

First Name

Middle Name

Primary Email

Citizenship

Current Address

Current City

Current State

Current Zip

Country of Birth

Alternate Address

Alternate City

Alternate State

Alternate Zip Code

*Alternate Email

Work Conducted at

Position

RIN

Division

Department

Current Telephone

Inventor Studio Class

Yes No

Inv Studio Term/Year

Non-RPI Contributors Only

Company/Institution Name & Address

Tech Transfer Contact Name, #, Email Address

Add remaining Contributors at the end of the Invention Disclosure Form.

Please email a full invention description, placing the invention title in the subject line, to: otc@rpi.edu

1. INVENTION TITLE

Use a brief descriptive title to aid in identifying the technology

2. DESCRIPTION OF INVENTION

2.1 Rationale

2.2 Novelty

2.3 Purpose

2.4 Limitations

2.5 Utility

2.6 Has this invention been reduced to practice?

3. DATE OF CONCEPTION AND PUBLIC DISCLOSURE

3.1 Date of Conception of Invention

3.2 Have you publicly disclosed?

Yes No

1st Public Disclosure Date

3.2.1 Title of first publication / presentation

3.2.2 Journal name or audience of first presentation

**If you have used Gov’t Funding for this invention, and you have already publicly disclosed, please send a copy of the publication to: otc@rpi.edu

3.3 Will you be publicly disclosing?

Yes No

Do you intend to disclose the invention publicly in the near future?

Future Public Disclosure Date

3.3.1 Title of future publication / presentation

3.3.2 Journal name or audience of future presentation

3.4 Proposed Technology Development Timeframe

*If you are planning to publicly disclose in the next 14 days, please contact Sherri Dente via email: dentes2@rpi.edu.
Public disclosure of an invention prior to filing a patent application can adversely affect patent rights.

4. FUNDING INFORMATION

Please identify all agencies, organizations, or companies that provided funding to the research that led to the conception of the invention. Obligations of the research sponsor(s) will have to be met if patent protection and/or licensing of the technology is pursued.

The invention was made under externally sponsored research (ex: Federal/State/Other)

Yes No

4.0 Select the Number of Funding Agencies Used

4.1 Agency

4.2 RPI Ref #

4.3 Award #

4.4 Funding Amt

4.5 PI’s Name

Using Above Format, Please Enter Remaining Agencies

The invention was made under internal funding (e.g. school and/or departmental/start-up/seed)

Yes No

The invention was made under independent research conducted at RPI

Yes

5. COMMERCIALIZATION and ENTREPRENEURSHIP

5.1 What companies do you believe would be interested in commercializing the invention?

5.2 Have you worked with/been approached by any companies regarding the invention? If yes, please list.

5.3 Identify similar products by names and manufacturers.

5.4 Can this technology be licensed to a start-up company?

Yes No Unsure

5.5 Are you interested in forming a start-up company?

Yes No Unsure

5.6 Marketing Abstract (Brief, Non-Confidential)

6. SIGNATURE THRUST AND KEYWORDS

Enter Keywords under the Signature Thrust(s) that is/are associated to your invention.

Select One or More Signature Thrusts

Biotechnology and the Life Sciences Computational Science and Engineering Energy, Environment, and Smart Systems Media, Arts, Science, and Technology Nanotechnology and Advanced Materials

6.1 Enter keywords for Biotechnology and the Life Sciences

6.2 Enter keywords for Computational Science and Engineering

6.3 Enter keywords for Energy, Environment, and Smart Systems

6.4 Enter keywords for Media, Arts, Science, and Technology

6.5 Enter keywords for Nanotechnology and Advanced Materials

6.6 Does this disclosure include biological matter? If yes, Please attach a list of materials for reference

Yes No

6.7 Is this a green/clean technology?

Yes No

6.7.1 If yes, please describe

7. SOFTWARE DEVELOPMENT

7.0 Does your invention involve or include software?

Yes No

7.1 Is the software standalone? If not, list associated software that is required for the invention to work.

7.2 What is the purpose of the software?

7.3 Is the software an improvement of existing software? Has a license been obtained on the existing software?

7.4 Are there any third party rights associated with the invention of the software? Describe

7.5 What language is the software developed in? If published, give nation of first publication

7.6 Is the software a proof-of-concept, a demonstration, prototype or fully functional end user version?

7.6.1 Year of Completion

7.7 Is there any user’s manual associated with the software, whether printed or digital?

Yes No

7.8 Has the source code for the program been disclosed to anyone other than the named developers?

Yes No

7.8.1 Identify the persons who received the source code and the circumstances, terms and conditions of the disclosure.

7.8.2 Were all such disclosures made subject to a confidentiality agreement?

Yes No

Please attach copies of the fully-signed confidentiality agreement(s).

8. CONTRIBUTOR INFORMATION

Contributors - An inventor, creator, or contributor, as used herein, is an individual who has conceived or provided an essential element of the invention, either independently or jointly with others, during the evolution of the technology concept or its reduction to practice.

8.1.1 With respect to the concept of the invention, in detail, what did the Rensselaer contributors contribute?

8.1.2 With respect to the concept of the invention, in detail, what did the non-RPI contributors contribute? (include dates)

CONTRIBUTOR 2

RPI Non-RPI

Last Name

First Name

Middle Name

Primary Email

Citizenship

Current Address

Current City

Current State

Current Zip

Country of Birth

Alternate Address

Alternate City

Alternate State

Alternate Zip Code

*Alternate Email

Work Conducted at

Position

RIN

Division

Department

Current Telephone

Inv Studio Term/Year

Non-RPI Contributors Only

Company/Institution Name & Address

Tech Transfer Contact Name, #, Email Address

CONTRIBUTOR 3

RPI Non-RPI

Last Name

First Name

Middle Name

Primary Email

Citizenship

Current Address

Current City

Current State

Current Zip

Country of Birth

Alternate Address

Alternate City

Alternate State

Alternate Zip Code

*Alternate Email

Work Conducted at

Position

RIN

Division

Department

Current Telephone

Inv Studio Term/Year

Non-RPI Contributors Only

Company/Institution Name & Address

Tech Transfer Contact Name, #, Email Address

CONTRIBUTOR 4

RPI Non-RPI

Last Name

First Name

Middle Name

Primary Email

Citizenship

Current Address

Current City

Current State

Current Zip

Country of Birth

Alternate Address

Alternate City

Alternate State

Alternate Zip Code

*Alternate Email

Work Conducted at

Position

RIN

Division

Department

Current Telephone

Inv Studio Term/Year

Non-RPI Contributors Only

Company/Institution Name & Address

Tech Transfer Contact Name, #, Email Address

CONTRIBUTOR 5

RPI Non-RPI

Last Name

First Name

Middle Name

Primary Email

Citizenship

Current Address

Current City

Current State

Current Zip

Country of Birth

Alternate Address

Alternate City

Alternate State

Alternate Zip Code

*Alternate Email

Work Conducted at

Position

RIN

Division

Department

Current Telephone

Inv Studio Term/Year

Non-RPI Contributors Only

Company/Institution Name & Address

Tech Transfer Contact Name, #, Email Address

CONTRIBUTOR 6

RPI Non-RPI

Last Name

First Name

Middle Name

Primary Email

Citizenship

Current Address

Current City

Current State

Current Zip

Country of Birth

Alternate Address

Alternate City

Alternate State

Alternate Zip Code

*Alternate Email

Work Conducted at

Position

RIN

Division

Department

Current Telephone

Inv Studio Term/Year

Non-RPI Contributors Only

Company/Institution Name & Address

Tech Transfer Contact Name, #, Email Address

CONTRIBUTOR 7

RPI Non-RPI

Last Name

First Name

Middle Name

Primary Email

Citizenship

Current Address

Current City

Current State

Current Zip

Country of Birth

Alternate Address

Alternate City

Alternate State

Alternate Zip Code

*Alternate Email

Work Conducted at

Position

RIN

Division

Department

Current Telephone

Inv Studio Term/Year

Non-RPI Contributors Only

Company/Institution Name & Address

Tech Transfer Contact Name, #, Email Address

CONTRIBUTOR 8

RPI Non-RPI

Last Name

First Name

Middle Name

Primary Email

Citizenship

Current Address

Current City

Current State

Current Zip

Country of Birth

Alternate Address

Alternate City

Alternate State

Alternate Zip Code

*Alternate Email

Work Conducted at

Position

RIN

Division

Department

Current Telephone

Inv Studio Term/Year

Non-RPI Contributors Only

Company/Institution Name & Address

Tech Transfer Contact Name, #, Email Address

Using Above Format, Please Enter Remaining Contributors

9. Inventor Comments

Comments

This form is currently in testing mode.

Rensselaer Polytechnic Institute

Invention Disclosure Form

LEAD CONTRIBUTOR

Non-RPI Contributors Only

Please email a full invention description, placing the invention title in the subject line, to: otc@rpi.edu

3. DATE OF CONCEPTION AND PUBLIC DISCLOSURE

4. FUNDING INFORMATION

5. COMMERCIALIZATION and ENTREPRENEURSHIP

6. SIGNATURE THRUST AND KEYWORDS

7. SOFTWARE DEVELOPMENT

8. CONTRIBUTOR INFORMATION

CONTRIBUTOR 2

Non-RPI Contributors Only

CONTRIBUTOR 3

Non-RPI Contributors Only

CONTRIBUTOR 4

Non-RPI Contributors Only

CONTRIBUTOR 5

Non-RPI Contributors Only

CONTRIBUTOR 6

Non-RPI Contributors Only

CONTRIBUTOR 7

Non-RPI Contributors Only

CONTRIBUTOR 8

Non-RPI Contributors Only