UT SOUTHWESTERN MEDICAL CENTER

INTELLECTUAL PROPERTY QUESTIONNAIRE

INSTRUCTIONS FOR COMPLETION

(1)	Describe the Invention. Use the same level of detail used in the Materials and Methods section of an academic paper.

(2)	Describe what the Invention does.

(3)	Describe how the Invention solves a problem, meets an unmet need, or improves upon an existing invention. This does not involve characterization of mechanism of action; there is no requirement that the mechanism of action be known at the time of filing a patent application.

(4)	Contributor Information: List all individuals who contributed to the research leading to the invention, irrespective of their position or role in the laboratory or clinic; this includes any contributing UTSW and non-UTSW employees. Provide contact information for ALL contributors. Identify individuals regardless of whether they may be thought of as co-inventors or co-authors. The guidelines for determining co-inventorship are distinct from those for determining co-authorship. Co-inventors must meet a required legal standard. A patent attorney retained by UT Southwestern will determine which contributors should be co-inventors in accordance with applicable law.

(5)	Publications and/or Oral Disclosures: Disclose or cite any of your publications describing the invention, whether in electronic or printed form. Provide details for any oral presentations describing the invention, whether live or recorded. List dates of any presentations and/or publication submissions that are scheduled.

If you have any questions, please contact the Office for Technology Development or call 214-648-1888.

THE UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER
INTELLECTUAL PROPERTY QUESTIONNAIRE

PLEASE TYPE OR PRINT CLEARLY, THEN RETURN TO

TECHNOLOGY DEVELOPMENT
UT Southwestern Mail Code 9094

DESCRIPTION OF THE INVENTION

Descriptive Title of Invention:

INTELLECTUAL PROPERTY DESCRIPTION
(Attach as many separate pages as may be necessary.)

Briefly summarize the invention, its use and purpose:

What particular features of the invention are unusual?

How does it differ from present technology?

What problem(s) does it solve?

What advantages over current technologies does it possess?

Type of invention or innovation (Select any that apply.):

☐ Biological material, including animals	☐ Chemical Compound	☐ Computer Software	☐ Device

☐ Diagnostic Test	☐ Method	☐ Research Reagent ☐ Service	☐ Work of authorship

Identify the diseases or condition affected by the invention:

Do you know of any specific companies that you believe would be interested in commercializing the invention, or have you communicated with any companies concerning the invention?

Names of all individuals who contributed to the research (see instructions on page one).

Attach additional pages if necessary.

PUBLICATIONS AND/OR ORAL DISCLOSURES

Identify any disclosures (either written, electronic, or oral) of the invention made, or scheduled to be made, to others. ATTACH A COPY OF THE PUBLICATION(S) OR DRAFT(S) THEREOF. Please also attach any relevant publications, including articles, abstracts or patent publications, which can provide background information to OTD and its patent counsel.

Disclosure

Title

Authors:

Type of disclosure (select):	☐ Written	☐ Oral	☐ Electronic
If written (select):	☐ Journal	☐ Abstract	☐ Poster ☐ Patent Publication
Publication Date:

Location of Presentation:

Disclosure category (select): ☐ Public ☐ Internal	☐ Confidential

If Confidential, was a Confidentiality Agreement signed?	☐ No	☐ Yes Date?

Provide descriptions of any additional disclosures on additional separate pages.

Were outside financial resources used in the funding of the work which created the invention? These are grants, gifts, and industry-sponsored research monies that were used to fund the creation or development of the invention.

(Select “No” or “Yes.”) Select “No” only if startup or departmental monies were used.

☐ No	☐ Yes

If yes, Technology Development will contact you for details of the funding source.

Corresponding Contributor Signature:

Please direct all questions to 214-648-1888 or TechnologyDevelopment@utsouthwestern.edu. Printed Name:	Department:	Date: