bidmc technology disclosure - Beth Israel Deaconess Medical Center

bidmc technology disclosure - Beth Israel Deaconess Medical Center

TECHNOLOGY VENTURES OFFICE
INVENTION DISCLOSURE FORM
A major teaching hospital
of Harvard Medical
School
The Disclosure Process:
This form serves both to notify the Technology Ventures Office (TVO) of your invention and as
a legal record of the invention and the date of conception. All completed disclosures are
reviewed by TVO senior staff at bimonthly Invention Review meetings and those judged
patentable and commercially viable are sent to outside patent counsel for further assessment of
patentability. When an invention is accepted as commercially viable, the TVO endeavors to work
closely with the inventor(s) to commercialize the technology.
Remember to disclose your inventions to this office BEFORE you publish or publicly present
your data! Public disclosure (see Section 4) of the invention may place severe limitations on
available patent protection.
What is patentable?
According to the US Patent Code, “Any new and useful process, machine, manufacture or
composition of matter, or any new and useful improvement thereof” is patentable. Under patent
law this is interpreted to include drugs, newly discovered, mutated or genetically engineered
microorganisms, vaccines, purified or recombinant proteins and peptides, isolated RNA or DNA,
hybrid cell cultures, antibodies, computer programs and processes for making/ purifying peptides
or proteins, processes for screening drug candidates, and diagnostic and therapeutic methods.
__________________________________________________________________________
Please submit both a signed original and an electronic copy of the completed form to the
licensing associate in the Technology Ventures Office for your Division as indicated on the TVO
website http://tvo.bidmc.harvard.edu under “Contact Us”.
Beth Israel Deaconess Medical Center
Technology Venture Office, BR2
109 Brookline Ave.
Boston, MA 02215
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Beth Israel Deaconess Medical Center
TVO use only
Disclosure received:
Disclosure No.
Technology Ventures Office
TECHNOLOGY DISCLOSURE
SUBMISSION INFO: Please submit both a signed original and an electronic copy of the
completed form to the licensing associate in the Technology Ventures Office for your Division
as indicated on the TVO website http://tvo.bidmc.harvard.edu under “Contact Us”.
1. TITLE OF INVENTION: (Brief, sufficiently descriptive to aid in identifying the invention)
2. SUPPORT BY THIRD PARTIES.
a. What funds supported the work leading to this invention? Include all non-BIDMC
sources of funding: government agencies, industrial sponsors, private agencies and others.
PI:
PI:
Sponsor:
Sponsor:
Grant No.
Grant No.
b. Was material (biological, chemical or physical) OBTAINED FROM OTHERS to create
this invention?
YES
NO
If yes, did a Material Transfer Agreement or other document accompany the transfer?
YES
NO
Please name the institution/company involved in this transfer and the material transferred:
______________________________________________________________________________
3. DESCRIPTION OF THE INVENTION. Please address the following:
If you wish to insert an image in this section, unprotect the document using the password “TVOBR2”.
a. Describe the invention.
b. Describe the unique feature(s) believed to be new and/or surprising and unexpected.
c. Describe the commercial product(s) that could be developed from this invention.
d. Describe the present stage of development (concept only, in vitro data, in vivo data
and/or clinical data) and the next steps you plan to take, if any.
e. Describe what is presently available or the standard of care in the field (therapy,
diagnostic, device, etc) and how your invention is/would be better (faster, cheaper, safer
and/or more effective).
____________________________________________________________________________
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4. PUBLIC DISCLOSURE / PUBLICATION PLANS: A public disclosure includes abstracts,
presentations at scientific meetings, public seminars, publications, awarded grants, disclosure to
others outside of BIDMC who have not signed a confidentiality agreement.
a. Identify dates and circumstances of any such disclosures and submit an electronic
copy of each along with your Disclosure.
b. Indicate your future disclosure or publication plans.
_____________________________________________________________________________
5. POTENTIAL LICENSEES. Provide as much detail as possible.
a. List any commercial entities that may be interested in licensing this invention.
b. List commercial entities, if any, that you specifically do not want contacted regarding
this technology and please indicate why.
6. IDENTIFICATION OF CONTRIBUTOR(S) AND ASSIGNMENT:
I/we assign all right, title and interest in this invention and any corresponding patents that
may be filed to the applicable entity in accordance with the Beth Israel Deaconess Medical
Center Research and Intellectual Property Policy.
A. Primary Contributor/Contact:
Signed Name: __________________________ Date: _______________
Typed name:
Institution:
Depart./Div.:
Tel.:
Email:
Citizenship (required by patent office):
Home Address (City, State required by patent office):
Indicate Intellectual Contribution:
Conception
Experimental Design
Brainstorming
____________________________________________________________________________
B. Other Contributors
Attach sheet as necessary or unprotect the document using the password “TVOBR2” to copy
and paste this section to accommodate additional contributors
Signed Name: __________________________ Date: __________________
Typed name:
Institution:
Depart./Div.:
Tel.:
Email:
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Citizenship (required by patent office):
Home Address (City, State required by patent office):
Indicate Intellectual Contribution:
Conception
Experimental Design
Brainstorming
______________________________________________________________________________
7. WITNESS STATEMENT. Arrange for a witness to sign who has read and understood the
disclosure; the witness may be a member of the TVO staff.
This invention was disclosed to and understood by me:
Witness Name:
Phone:
Witness Signature: ___________________________
Date:______________
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