IMPORTANT INFORMATION ABOUT THIS FORM AND YOUR …

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4667339262890?00?INVENTION DISCLOSURE FORMIMPORTANT INFORMATION ABOUT THIS FORM AND YOUR DISCLOSURENew concepts may deliver value measured in many ways. Concepts developed at the Cleveland Clinic are candidates for further commercial development if they provide evidence of both clinical and economic value. As used in this document, “Invention” shall mean a unique or novel concept that can be or has been reduced to practice in ways that were previously not obvious. The information collected in this form will be used to quickly assess the commercial potential of what is being disclosed. It should be clear that a concept or invention exists and the concept or invention has the potential to create significant commercial value.INVENTION TITLEDISCLOSURE DATEEnter Invention TitleSelect DateDISCLOSURE DETAILSList all persons who have directly contributed in the development or conception of the invention. If there are more than 3 contributors, please use a separate sheet.INVENTOR/CONTRIBUTOR (Lead*)INVENTOR/CONTRIBUTOR 1INVENTOR/CONTRIBUTOR 2FULL NAMEEnter Full NameEnter Full NameEnter Full NameCC DEPARTMENT & INSTITUTEEnter Department & InstituteEnter Department & InstituteEnter Department & InstituteHOME ADDRESSEnter Home AddressEnter Home AddressEnter Home AddressPHONEEnter Phone NumberEnter Phone NumberEnter Phone NumberEMAILEnter EmailEnter EmailEnter EmailEMPLOYEE # Enter Employee #Enter Employee #Enter Employee #% CONTRIBUTION**Enter % ContributionEnter % ContributionEnter % ContributionSIGNATUREDEPARTMENT CHAIRDEPARTMENT/DIVISIONDATESIGNATUREEnter Full NameClick here to enter text.Select Date*The Lead will be Innovations’ main contact for the invention and is responsible for sharing correspondence with other inventors/contributors listed on this document and assisting in the completion of tasks.**% Contribution indicates the percentage that each inventor/contributor would receive from the inventor portion of commercialization revenue, if any, as provided in Cleveland Clinic’s Intellectual Property and Commercialization Policy (updated as of Jan 1, 2018) (“the CCF IP Policy”) or the CCF IP Policy in effect at the time of invention disclosure. Contributors: Actual named inventors/contributors on filed patent applications, if any, will be determined according to US patent law. Assignment: By signing this invention disclosure, each contributor who is considered “CCF Personnel” under the CCF IP Policy hereby assigns all rights, titles and interests to The Cleveland Clinic Foundation and denotes that the contributor also agrees to cooperate in the filing of patent applications and the commercialization of the technology.Invention Domain (Type an “X” in the box next to the most appropriate invention domain)[ ]Medical Device[ ]Health Information Technology[ ]Therapeutics & Diagnostics[ ]Delivery Solutions 1a. Provide a brief description of the proposed concept.Additional support in the form of attached documentation is welcome for any submission. Government funded projects should attach support (e.g. manuscript). Please provide a brief description of the proposed concept.1b. Please indicate the maturity of the concept (type “X” next to the most suitable description)[ ]Problem – An issue, that if addressed would result in meaningful benefit (value) to one or more users[ ]Idea – A new concept, novel materials, targets, or pathways that if enabled would be valuable to one or more users [ ]Proof of Concept – The first version of the concept used to evaluate value and plan future development activities. For RxDx, this could include models, completed target validation, or working assays.[ ]Prototype – A more mature iteration of the proven concept that can be used to demonstrate value. For RxDx, this could include a tool compound, composition of matter, or verified assays.[ ]Minimally Viable Product (MVP) – A version of the concept that could be used by a customer to achieve the intended value.For RxDx, this could include a development candidate or a validated assay.[ ]Product – A version of the concept that could be sold in its current form to buyers in the pursuit of the stated value1c. Please provide the top three key/most valuable features.A feature is defining characteristic of the concept that should differentiate it from other concepts and provide value to one or more users.Feature NameIntended User(s): Enter Feature NameEnter First User’s Title/RoleEnter Second User’s Title/RoleEnter Third User’s Title/RoleValue Derived (Benefit of the Feature)Source Evidence (Publication/Guideline/URL/Link/Etc.)1Enter Value of the Feature Enter Source Evidence2Enter Value of the Feature Enter Source Evidence3Enter Value of the Feature Enter Source EvidenceFeature NameIntended User(s): Enter Feature NameEnter First User’s Title/RoleEnter Second User’s Title/RoleEnter Third User’s Title/RoleValue Derived (Benefit of the Feature)Source Evidence (Publication/Guideline/URL/Link/Etc.)1Enter Value of the Feature Enter Source Evidence2Enter Value of the Feature Enter Source Evidence3Enter Value of the Feature Enter Source EvidenceFeature NameIntended User(s): Enter Feature NameEnter First User’s Title/RoleEnter Second User’s Title/RoleEnter Third User’s Title/RoleValue Derived (Benefit of the Feature)Source Evidence (Publication/Guideline/URL/Link/Etc.)1Enter Value of the Feature Enter Source Evidence2Enter Value of the Feature Enter Source Evidence3Enter Value of the Feature Enter Source Evidence1d. If possible, please estimate how much time you/fellow contributors have invested in enabling the concept? (hours)Enter hours of effort to enable the concept.1e. Do you have research time or protected time to invest in this effort moving? (Yes/no) If yes, how much? (hours)[ ]Yes- hours [ Enter Hours ][ ]No2a. List any Inventors with a Dual Appointment with the U.S. Department of Veterans Affairs.NameAppointment DateEnter Contributor NameSelect Appointment DateEnter Contributor NameSelect Appointment Date2b. Have you received any grant funding* that is associated with this concept? [ ]Yes[ ]No*CC is required to report Government funded inventions to relevant funding agencies and provide a written description of the invention in technical detail. In order to comply with this reporting, an invention must exist and the invention must be a Subject Invention defined as any invention conceived or first actually reduced to practice, in the performance of work under Grant(s). Noncompliance with Federal reporting requirements may result in the termination of grant funding. Please see link for our obligations under the Bayh-Dole Act.If Yes, please provide the below information: Grant Number (s)Amount(s) AwardedFunding Source(s)Publication(s) Supporting GrantProvide URL/Link to PaperEnter Grant NumberEnter AmountEnter Funding SourceEnter Publication(s)Enter Grant NumberEnter AmountEnter Funding SourceEnter Publication(s)2c. Have you received any additional funding associated with this concept?[ ]Yes[ ]NoIf Yes, please provide the below information: Funding EntityAmount(s) Enter Funding EntityEnter Amount(s)Enter Funding EntityEnter Amount(s)2d. If possible, please estimate the amount of funding that might be necessary to enable the concept more completely?Enter funding estimate and funding support here3. Has this invention been publically disclosed? If yes, please list date and details.A public disclosure refers to a communication of an idea or invention without any confidentiality obligations, either written or oral. This includes: oral presentations, publications, posters, grant applications, web based document, job talk and/or grand rounds. Public disclosure may limit the rights of The Cleveland Clinic and the inventor(s). Enter details of public disclosure here4. Please list the closest comparable products found in the market today.Product NameFeatureCompany NameReference URL/LinkEnter Product NameEnter Product Feature.Enter Company NameEnter ReferenceEnter Product NameEnter Product Feature.Enter Company NameEnter ReferenceEnter Product NameEnter Product Feature.Enter Company NameEnter Reference5. If known, please estimate the size of the commercial opportunity.Opportunity Size = (Estimated Users OR Estimated Units) X Estimated PriceEnter estimated commercial opportunity.6. Please list any industry contacts or potential licensees that could be pursued for this pany NameContact NameContact RoleContact InformationProfile URL/LinkEnter Company NameEnter Contact NameEnter Contact RoleEnter Contact InformationEnter URL/LinkEnter Company NameEnter Contact NameEnter Contact RoleEnter Contact InformationEnter URL/LinkEnter Company NameEnter Contact NameEnter Contact RoleEnter Contact InformationEnter URL/Link7. Please list or provide links to any known publications or intellectual property that are relevant to your invention.This includes literature or existing intellectual property that supports your invention and/or can be used to demonstrate its novelty.Enter known publication or intellectual property relevant to the invention ................
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