Emory Intellectual Property Disclosure Form - Office Of Technology

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Confidential Information

File No. _____________

When completed submit to:

Emory Intellectual Property

Disclosure Statement Form

Office of Technology Transfer

1599 Clifton Rd., NE, 4

Floor

Atlanta, Georgia 30322

(404) 727-2211

The purpose of this form is to facilitate the prompt disclosure by Emory Personnel of any Intellectual Property to which Emory may assert ownership rights

pursuant to Section I of the Emory University Intellectual Property Policy effective March 15, 2011. Please review the attached instructions and guidelines.

1. Title of Intellectual Property

2. Type of Intellectual Property

Diagnostics

Drug Discovery

Medical Device

Micro & Nanotechnology

Non-Therapeutics

Research Tools

Vaccine

Softw are

Therapeutics

3. Please attach a description with technical detail sufficient to convey a clear understanding, to the extent currently known, of the nature, purpose,

operation, and the physical, chemical, biological or electrical characteristics of the invention.

4. Legal Name of Contributor

Position

Department

Emory

CHOA

Other

Employee

Institution

(No Nicknames)

Contribution

Tech

(name)

Last Name

First Name

Please do not

provide SSN

____%

Please list all persons who are believed to have made significant contributions to the Intellectual Property including Emory Personnel as well as other

Contributors at other institutions. Determination of inventorship is a legal matter and will be determined by legal counsel.

5. What funds were used to develop this intellectual property? Please check all that apply

Government Grant? Grant No(s)_______________________________________Agency__________________ PI ________________________

Foundation Grant?

Sponsor(s) _______________________________________________________ OSP #____________________________

Industry Sponsor?

Sponsor(s) _______________________________________________________ OSP #____________________________

Discretionary or department funds?

_____________________________________________________________________________________

Other?

_____________________________________________________________________________________________________________

Yes