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G-40, University of California Patent Program, Appendix D, Disclosure
and Record of Invention Form
August 1, 1994
(Office of Technology Transfer address/telephone information
(below) updated 9/99)
Office of Technology Transfer PROPRIETARY INFORMATION
DISCLOSURE AND RECORD OF INVENTION FORM
APPENDIX D
........................................................................
Note: When completed, the Disclosure and Record of Invention Form is an
important legal document. Care should be taken in its preparation.
Please refer to accompanying instructions. If you desire
assistance, call the Office of Technology Transfer (University
Patent Office) at (510) 587-6000. Information contained in this
document is maintained in confidence by the University Patent
Office and normally will not be released to others except with
attorney-client privilege, to research sponsors as required by
contract, or under appropriate secrecy agreements, until a
patent application is filed, the information is published, a
determination not to file a patent application is made, or as
may be required by law. The information contained should not be
disclosed to others outside the University, except as described in
section 9, without the approval of the University Office of
Technology Transfer. It is not the practice of the University of
Technology Transfer to send your Record of Invention to other
University employees for peer review.
1. Short descriptive title of the invention.
2. A. Briefly summarize the invention here. Include the novel features
and advantages.
B. Detailed description of the invention using additional sheets as
necessary and attach as appendix.
3. List the funding source(s) for the project under which this invention
was made. If applicable, identify by contract or grant number and
name the Principal Investigator/Supervisor of each.
Contract or Principal Investigator/
Funding Source/Sponsor Grant Number Supervisor
4. For any "Inventor" named (item 13) who is not employed full-time by
the University of California, please identify other employers (e.g,
Veterans Administration, Howard Hughes Medical Institute, USDA), the
percent of salary time funded by such other employer, and the nature of
the other employment (such as research, teaching or clinical duties).
5. When did you first conceive this invention?
6. What is the date of the first written record (notebook, letter,
proposal, drawing, etc.) of this invention? Identify the document, page
numbers involved, and location of the document.
7. When did you first successfully test this invention?
8. If you have disclosed this invention to non-UC personnel (including
research sponsor) then indicate when, under what circumstances, and to
whom.
a. orally
b. in writing
c. by actual use, demonstration, or posters
9. Have you submitted or do you plan to submit a report, abstract, paper
or thesis relating to this invention for publication, for presentation
at a conference, or to a research sponsor?
If yes, give details, including the actual or planned date of
submission. If a manuscript has been accepted, give the anticipated
publication date. Append a copy of the latest draft manuscript
available. (See instructions for the effect of publication prior to
the filing of a patent application.)
10. Identify any references, patent applications, or other publications
of which you are aware and which you believe to be pertinent to this
invention. Please attach a copy of each of these references, if
available.
11. If any proprietary material (e.g, cell line, antibody, plasmid,
computer software, or chemical compound) obtained from outside your
laboratory was used to develop this invention under a restrictive
written or oral transfer agreement (other than a normal purchasing
agreement), please attach a copy or summary of that agreement.
12. List companies you believe might be interested in using, developing
or marketing this invention.
13. Signatures, Names and Addresses of Inventors
a) b)
Signature Date Signature Date
Print Name Print Name
Dept/ORU Dept/ORU
Rm & Bldg Rm & Bldg
Campus (Address if non-UC) Campus (Address if non-UC)
City/State/Zip City/State/Zip
Telephone Telephone
Note: If there are more inventors please provide signatures, names and
addresses on an additional sheet of paper,
14. Technically Qualified Witnesses (Two Required)-invention disclosed
to and understood by:
a) b)
Signature Date Signature Date
Print Name Print Name
Submit this form with ORIGINAL SIGNATURES directly to:
Director--Office of Technology Transfer
Office of the President
University of California
1111 Franklin St., 5th Floor
Oakland, CA 94607-5200
If you do not receive an acknowledgment with 30 days, please call the
University Office of Technology Transfer at (510) 587-6000.
NOTE: DISTRIBUTION OF COPIES OF A COMPLETED FORM TO THIRD PARTIES IS
EXPRESSLY PROHIBITED, AS PROPRIETARY UNIVERSITY INFORMATION IS
CONTAINED IN ANY COMPLETED FORM.
Effective 1/1/82 Retention: 7 yrs after last patent expires
Revised 4/91 or 10 yrs after the date of the
last action whichever is later
C)1999 The Regents of the University of California
All Rights Reserved
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