ࡱ>  ,bjbjVV 4<<$3338k|3ZM4###*<"#%L'L'L'L'L'L'LOQ~'L$**$$'L##M***$F##%L*$%L**=GJ# 3%H$L*M0ZMH$S%$SHJ$SJ$$*$$$$$'L'L*$$$ZM$$$$$S$$$$$$$$$ :  This electronic form is to be followed when preparing your report of invention. Please provide a response for each item listed below. 1. Title of Invention.  FORMTEXT       2. List all inventors who intellectually contributed to the invention. Please also indicate any joint or special appointment with non-VA institutions. VA inventor(s): include Without Compensation (WOC) and Intergovernmental Personnel Agreement (IPA) employees. Name: FORMTEXT       Position: FORMTEXT       Work Address: FORMTEXT       Work Phone: FORMTEXT       Email: FORMTEXT       Name: FORMTEXT       Position: FORMTEXT       Work Address: FORMTEXT       Work Phone: FORMTEXT       Email: FORMTEXT       Name: FORMTEXT       Position: FORMTEXT       Work Address: FORMTEXT       Work Phone: FORMTEXT       Email: FORMTEXT       Non- VA inventor(s): Name: FORMTEXT       Position: FORMTEXT       Work Address: FORMTEXT       Work Phone: FORMTEXT       Email: FORMTEXT       Name: FORMTEXT       Position: FORMTEXT       Work Address: FORMTEXT       Work Phone: FORMTEXT       Email: FORMTEXT       Name: FORMTEXT       Position: FORMTEXT       Work Address: FORMTEXT       Work Phone: FORMTEXT       Email: FORMTEXT       *Please attach a separate page for additional inventors. 3. Please provide a brief statement describing each VA inventor s research duties and responsibilities for the VA at the time the invention was made. Was the inventor(s) hired to perform research for VA under Title 5? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If Yes, please include a copy of that inventors Position Description (PD). Does the inventor(s) receive VA research funding, such as Merit Review Grants? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If Yes, please list the titles of the grants covering the time period this invention was made.  FORMTEXT       Has the inventor(s) received permission to work on research projects, whether funded by VA or not, during their official VA tour of duty? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If Yes, please list the titles of the projects covering the time period this invention was made.  FORMTEXT       d) Was the inventor(s) paid under an Intergovernmental Personnel Agreement (IPA) at the time the invention was made? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If Yes, please attach a copy of the IPA. Does the inventor(s) hold a Without Compensation (WOC) Appointment at the time the invention was made? YES  FORMCHECKBOX  NO  FORMCHECKBOX  If Yes, please attach a copy of the inventors VA-WOC Intellectual Property Agreement. 4. Name and address of the facility at which the invention was made.  FORMTEXT       5. Contribution of the VA to the invention in staff, amount if funds, equipment, facilities, materials/or supplies.  FORMTEXT        FORMTEXT       6. Please list all other government contribution, such as NIH grants. 7. Contribution of any non-government organizations, including a university or institution of higher learning, to the invention in staff, amount of funds, equipment, facilities, materials/or supplies, time or services on official duty for such entity. (Please indicate the source, nature, and value of contribution).  FORMTEXT       8. Description of Events: This information is important for deciding priority and/or legal  bars to patenting. In general, publications, in any medium, before the date a formal patent application is filed in a national patent office can cause a bar to patent filing in most foreign countries. While US patent law allows inventors up to one year to file a patent application after the first publication, public use, or sale, the loss of foreign rights is often very important to potential industrial licensees Initial conception of the idea: Date: FORMTEXT       Notebook:  FORMCHECKBOX Letter:  FORMCHECKBOX Email:  FORMCHECKBOX Oral:  FORMCHECKBOX to whom: FORMTEXT       First description of complete invention, oral or written: Date: FORMTEXT       Notebook:  FORMCHECKBOX Letter:  FORMCHECKBOX Email:  FORMCHECKBOX Oral:  FORMCHECKBOX to whom: FORMTEXT       First successful demonstration (first actual reduction to practice): Date: FORMTEXT       Notebook:  FORMCHECKBOX Letter:  FORMCHECKBOX Email:  FORMCHECKBOX Oral:  FORMCHECKBOX to whom: FORMTEXT       Has this work been: Submitted for publication? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Date:  FORMTEXT       Accepted for publication? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Date: FORMTEXT       Published? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Date: FORMTEXT       If published, journal citation:  FORMTEXT       Please attach copy. Have you presented this work at a conference or meeting? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Did you submit an abstract? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Was abstract published? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Name of conference or meeting  FORMTEXT       Did presentation include handouts? 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Describe the invention completely, using the outline given below. Sketches, prints, photos, and any pertinent manuscript should be attached to this disclosure. Manuscripts generally following the outline are acceptable substitutes. General Purpose. State in general terms the purpose and object of the invention. b. Background. Describe the prior art (identify by patent number or journal citation, if possible) and indicate how the invention differs and is more advantageous than prior art. c. Description and Operation. Describe completely (sufficient to permit the preparation of a patent application), the construction of the invention using reference characters to identify components in attached illustrations. Give a description of one complete operational cycle. If the invention relates to the synthesis or identification of a new composition of matter, describe the product in a structured form, if possible, and the process of making it. Include all available information regarding its physical characteristics and all test data evidencing its utility. d. Non-Technical Description. Describe on one page or less (double-spaced) the invention in terms understandable to non-scientists. 10. State any reasons for applying for a patent, or why publication would not be adequate to promote the availability of the invention to the public.  FORMTEXT       11. State whether any other party or institution is interested in filing and administering a patent application on the invention.  FORMTEXT       12. Any planned publication of description of the invention that would enable someone skilled in the technology to which the invention pertains to make and use the invention.  FORMTEXT        FORMTEXT       13. State whether the invention has previously been disclosed, as for example, description and date of any sale or public use of the invention in the United States. Description should specify if the use was operational, or for testing purposes, and if there was any effort or intention to maintain the invention in secrecy after the operational use commenced. 14. Patent Application number and origin, if already filed.  FORMTEXT       15. Has a biological, chemical or physical material or substance obtained from others been used in the creation of this invention? YES  FORMCHECKBOX  NO  FORMCHECKBOX  a) If Yes, was a Material Transfer Agreement or similar document used to obtain the material or substance? YES  FORMCHECKBOX  NO  FORMCHECKBOX  b) If Yes, attach a copy of the agreement 16. Was this invention derived under a contractual agreement with a company or institution such as a Sponsored Research Agreement or Clinical Trial Agreement? YES  FORMCHECKBOX  NO  FORMCHECKBOX  a) If Yes, please indicate the name of the company/sponsor and title of the study.  FORMTEXT       I attest that the responses above are accurate and correct. Signature:______________________________ ___________________ (Inventor) Date I attest that the responses above are accurate and correct. Signature:______________________________ ___________________ (Immediate Supervisor) Date I attest that the responses above are accurate and correct. Signature:______________________________ ___________________ (ACOS R&D Office) Date 17. Attach a signed HYPERLINK "http://www.vard.org/tts/pat/patcert.pdf"Certification for each VA inventor and each WOC inventor that are listed for this invention. 18. Execution of the disclosure: The end of the disclosure is to be signed and dated by the inventor(s). The disclosure and certification forms are to be reviewed and signed by the inventor's immediate supervisor and the ACOS for Research, attesting to the accuracy of the statements. If the ACOS disagrees with the information submitted, then a separate statement will be submitted with an explanation. 19. 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