ࡱ> {}z d<bjbjDD z&uo_&uo_3F F $Pts'WR(Z_$='?'?'?'?'?'?'$)x,|c'c'4x'/ / / p&j/ ='/ / :%|%ppʴN% &'0'% -U-%-%,/ c'c'L'-F Q: INVENTION DISCLOSURE RECORD Date This Record Was Completed: Total Number of Pages, Including all Attachments: Descriptive Title of Invention: Departments: Sponsors:  FORMCHECKBOX  Federal  FORMCHECKBOX  Industry  FORMCHECKBOX  University  FORMCHECKBOX  Foundation  FORMCHECKBOX  Other Name of Agency: Grant No.: INSTRUCTIONS: Please provide the information requested below. The value of this record both as evidence of your invention and to assist the Colleges attorneys obtain valid patents depends upon the accuracy and completeness of this document. A clear detailed disclosure can help substantially expedite the application drafting process. Where necessary, use more space and/or attach additional sheets. Further, please review the Colleges Intellectual Property Policy that can be found at:  HYPERLINK "http://www3.davidson.edu/cms/x4485.xml" http://www3.davidson.edu/cms/x4485.xml Conception of Invention First conceived (thought of) on or about: __________________________________________ By: Date of first sketch or drawings In whose files? Date of first written description: In whose files? First Disclosure (Oral or Written) of Invention Date of first disclosure within the College: To whom? Dates of first disclosures outside the College, if any: Date first disclosed to vendors/contractors: To whom: Under secrecy/confidentiality agreement? Yes: _____ No: _____ Date first disclosed to sales reps/buyers/customers: To whom: Under secrecy/confidentiality agreement? Yes: _____ No: ______ On Sale Was the invention offered for sale or sold, or are there any immediate plans to do so? Yes: _______ No: _______ Date of earliest actual or planned sales activity: Where and with whom: Identify any sales contracts: Public Use or Disclosure Date of first actual shipment: Date of first planned shipment: Was the invention operated or displayed publicly, e.g., at trade shows, conferences, etc., or are there plans to do so? Yes: ______ No: _____ If yes, where and when: Was the invention disclosed in any articles, magazines, papers, patents, patent applications, or is it planned to do so? Yes: ______ No: ______ If yes, name(s) and date(s) of actual/planned disclosure(s) below: Names: Dates: Is the invention in actual use? Yes: ______ No: _______ If use is outside the College, is/was it: under secrecy agreement? Yes: ______ No: _______ to test operability? Yes: ______ No: _______ pursuant to a contract? Yes: ______ No: _______ Foreign Patent Protection Is there interest in filing for any foreign patents on this invention? Yes: ______ No: _______ Maybe:______ Detailed Description of Invention Describe the invention and its operation in detail. The description should include a detailed disclosure of the invention with specificity as to the inventive features and a description of the best mode of practicing the invention. Please attach and refer to pertinent sketches, drawings, graphs, etc., with the aid of reference characters to assist in describing the subject matter of the invention. Where the invention involves processes, give ranges of temperatures, pressures, times or any other pertinent process variables. For mechanical inventions we strongly recommend including drawings that display and identify each component of the invention. For electrical inventions we recommend including schematic diagrams. For processes, business methods and software-related inventions, we strongly recommend including detailed flow charts, block diagrams and network diagrams. A clear, detailed, comprehensive description can help substantially expedite the application drafting process. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Identify and attach literature on the closest technology related to this invention found in: Prior products or processes: Patents or other literature, including publications, articles or patent applications: The College Case Nos. of any related inventions: Explain in detail why you created this invention (include problems with prior products or processes): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ State what features of the invention you consider to be new and explain how the invention improves over previously-known devices or processes: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Please describe the primary benefits to a potential customer or user for any products, services, or commercial processes that might be developed from this technology (e.g., what could it do to help a potential customer: lower expenses, increase productivity, efficiency or accuracy, minimize risk, simplify a process, overcome a defect, increase revenue, promote safety?). _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ What are the competing alternatives or substitutes? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ How would you design around your own invention, accomplishing an equivalent objective in a different way? List as many different alternative embodiments as possible. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Identify all drawings, prints, photos, reports, and/or notebooks relating to the invention: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Actual Reduction To Practice Was a prototype constructed? Yes: ______ No:_________ If yes, by whom: Date started: __________ Date completed: ________________ Where is device now? Was device tested? Yes: _______ No: _________ If yes, by whom: Date started: __________ Date completed: _____________ Did test(s) demonstrate operability of invention for intended purposes? Yes: _______ No: ________ Describe test and results: Any witnesses to testing: Names: Dates: If witnesses are outside The College, are they under secrecy agreement? Yes: _______ No: ________ Government Contract -- Was the invention: Conceived: Yes: _____ No: _____ Constructed: Yes: _____ No: _____ Tested: Yes: _____ No: _____ during performance of a Government contract? If yes to any of the above, what is the contract number (Give Full Contract Number) Inventorship Identify each person who contributed to the concept or development of this invention, including any contributors outside the College. Briefly describe the nature of each person's contribution. For each person include their full name, address, telephone number, fax number and email address. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Provide complete information for each submitter and have each submitter, and two witnesses (the College employees) who understand the invention, sign and date at the appropriate places. SUBMITTER 1: Last First Middle Home address: City County State Zip Code Citizenship: Email: Telephone Number Work: Home: Signature of Submitter: Date: SUBMITTER 2: Last First Middle Home address: City County State Zip Code Citizenship: Email: Telephone Number Work: Home: Signature of Submitter: Date: Witnesses WITNESSED AND UNDERSTOOD BY DATE Signature Print Name WITNESSED AND UNDERSTOOD BY DATE Signature Print Name Return completed form to: Intellectual Property Advisory Committee of 91ɬ     PRIVILEGED & CONFIDENTIAL PAGE 7 PAGE 7 Active\6560744.1  PRIVILEGED & CONFIDENTIAL Active\6560744.1   >?@ABsvw³񣔄uiYuYJJhrch3>CJOJQJ^Jhrch#k5>*CJOJQJ^JhS CJOJQJ^Jhrch#k5CJOJQJ^Jhrchot>*CJOJQJ^JhrchotCJOJQJ^Jhrch3>>*CJOJQJ^Jhrch/CJOJQJ^Jhrch/>*CJOJQJ^Jhrch1CJOJQJ^Jhrchx>*CJOJQJ^JhrchxCJOJQJ^JABvwx /`0p@ P !D%gd3> /`0p@ P !D%gd#k5! /`0p@ P !D%]gd#k5 $@gd#k5 /`0p@ P !$ o   j {+ ;`00p 0p0p0!p#"^`"gd#k5`gd3> p^`gd\f /`0p@ P !D%gd3> ;`00p 0p0p0!p#        + , - 9 : H I J W X f g h 8 ? ݱݛ݅o__PhrchxCJOJQJ^Jhrch3>>*CJOJQJ^J+jhrch3>CJOJQJU^J+j\hrch3>CJOJQJU^J+jhrch3>CJOJQJU^J+jthrchrcCJOJQJU^J+jhrchrcCJOJQJU^Jhrch3>CJOJQJ^J%jhrch3>CJOJQJU^J? >  j q 񵢓}l\J;hrch#k5CJOJQJ^J"hrchx5>*CJOJQJ^Jhrchx5CJOJQJ^J hrchrc0JCJOJQJ^J+jDhrchrcCJOJQJU^JhrchrcCJOJQJ^J%jhrchrcCJOJQJU^Jhrch3>CJOJQJ^Jhrch mCJOJQJ^Jhrchz0CJOJQJ^JhrchtCJOJQJ^JhrchxCJOJQJ^Jq     % 1 2 3 4 c Сo`Qhrch3>CJOJQJ^JhrchtCJOJQJ^J"hrchx5>*CJOJQJ^Jhrchx5CJOJQJ^Jhrcht>*CJOJQJ^Jhrchrc>*CJOJQJ^Jhrch/>*CJOJQJ^JhrchxCJOJQJ^Jhrchx>*CJOJQJ^Jhrch#k5CJOJQJ^Jhrch#k5>*CJOJQJ^Jj  2 3 d e d+ ;`00p 0p0pD%%^`gd#k5* 8`00p 0p0pD%^`gd/ ;`00p 0p0p0!p## ;`00p 0p0p0!D%gd#k5 e ,eA# ;`00p 0p0p0!D%gd#k5 ;`00p 0p0p0!p#( ;`00p 0p0p0!p#^`# ;`00p 0p0pD%%gd/+ ;`00p 0p0p0!D%^`gd#k5 "%+,09EF(*ҳҤ҅vҤffWh\f5>*CJOJQJ^JhrchNH>*CJOJQJ^Jhrch#k5CJOJQJ^Jhrch#k5>*CJOJQJ^Jhrch3>CJOJQJ^Jhrch2UCJOJQJ^JhrchtCJOJQJ^Jhrchx>*CJOJQJ^JhrchxCJOJQJ^Jhrch/>*CJOJQJ^Jhrch/CJOJQJ^J,F'jj>+$$ ;`00p 0p0p0!p#^`&$$ ;`00p 0p0p0!D%gdNH ;`00p 0p0p0!p#( ;`00p 0p0p0!p#^`# ;`00p 0p0p0!D%gd#k5'()*23j( ;`00p 0p0p0!p#^` ;`00p 0p0p0!p#( ;`00p 0p0p0!p#P^`P"$ ;`00p 0p0p0!p#*1A]'345M[oyzFU_`GNVXY]dgijnu߲߲߲߲߲߲ߢߢߢsߢhrchtCJOJQJ^JhrchNH>*CJOJQJ^Jhrchx>*CJOJQJ^Jhrcht>*CJOJQJ^JhrchNHCJOJQJ^Jhrch2UCJOJQJ^JhrchBICJOJQJ^JhrchxCJOJQJ^J"hrchx5>*CJOJQJ^J-45Na8( ;`00p 0p0p0!p#P^`P- >`00p 0p0p0!p#D%^`gdt ;`00p 0p0p0!p## ;`00p 0p0p0!D%gdt+ ;`00p 0p0p0!D%^`gdtNOz{9:`ae# ;`00p 0p0p0!D%gdt( ;`00p 0p0p0!p#^`+ ;`00p 0p0p0!D%^`gdt ;`00p 0p0p0!p# =>Yj{+^( ;`00p 0p0p0!p#^`# ;`00p 0p0p0!D%gdt ;`00p 0p0p0!p#uxz{DE&G³¤•‰whVGhrch mCJOJQJ^J"hrch m5>*CJOJQJ^Jhrch2UCJOJQJ^J"hrch2U5>*CJOJQJ^JhS CJOJQJ^Jhrch3>CJOJQJ^JhrchYCJOJQJ^JhrchNHCJOJQJ^JhrchxCJOJQJ^Jhrchx>*CJOJQJ^Jhrcht>*CJOJQJ^JhrchtCJOJQJ^J%&HIh%$ ;`00p 0p0p0!p#gd m-$ ;`00p 0p0p0!p#P^`Pgd m# ;`00p 0p0p0!p#gd2U ;`00p 0p0p0!p#I/wO'oGg?&$$ ;`00p 0p0p0!p#gd m.$$ ;`00p 0p0p0!p#^`gd m/' ( C D a b ! !!!D$H$n$$'())*++-,ѳѳѣѳффufufuWhrchSsCJOJQJ^JhrchhsCJOJQJ^JhrchotCJOJQJ^Jhrchk2CJOJQJ^Jhrchx>*CJOJQJ^JhrchNH>*CJOJQJ^JhrchNHCJOJQJ^Jhrch3>CJOJQJ^JhrchxCJOJQJ^Jhrch mCJOJQJ^Jhrch m>*CJOJQJ^J!?_7+ ;`00p 0p0p0!p#^`gd m%$ ;`00p 0p0p0!p#gd m&$$ ;`00p 0p0p0!p#gd m & ' D S b c !+$$ ;`00p 0p0p0!p#0^0`#$$ ;`00p 0p0p0!p#+$$ ;`00p 0p0p0!p#^` !!! 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