TECHNOLOGY VENTURES OFFICE INVENTION DISCLOSURE FORM

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.

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Please submit both a signed original and an electronic copy of the completed form to the Senior Associate in the Technology Ventures Office for your Division as indicated on the TVO website http://tvo.bidmc.org under “Contact Us”.

Beth Israel Deaconess Medical Center Technology Venture Office, BR2 109 Brookline Ave. Boston, MA 02215

1 CONFIDENTIAL Beth Israel Deaconess Medical Center TVO use only Technology Ventures Office Disclosure received: Disclosure No.

A. TECHNOLOGY DISCLOSURE

SUBMISSION INFO: Please submit both a signed original and an electronic copy of the completed form to the Senior Associate in the Technology Ventures Office for your Division as indicated on the TVO website http://tvo.bidmc.org under “Contact Us”.

1. TITLE OF INVENTION: (Brief, sufficiently descriptive to aid in identifying the invention)

2. SUPPORT BY THIRD PARTIES: a. Did non-BIDMC sources of funding, i. e. government agencies, industrial sponsors, private agencies or foundation grants, support the work leading to this invention? B. C. YES ☐ NO ☐

If yes, please list all sources of funding by completing the following in detail.

PI: Sponsor: Grant No. PI: Sponsor: Grant No. b. Was material (biological, chemical or physical) OBTAINED FROM OTHERS to create this invention? D. 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:

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3. DESCRIPTION OF THE INVENTION: Please address the following (using additional pages if necessary). a. Describe the invention. The description should be sufficiently complete in technical detail to convey a clear understanding to the extent known at the time of the disclosure, of the nature, purpose, operation, and the physical, chemical, biological or electrical characteristics of the invention.

2 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. Identify future disclosures and publication plans, i.e. abstracts, manuscripts, and submit an electronic copy of each, in its current form, along with your Disclosure.

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5. POTENTIAL LICENSEES: Provide as much detail as possible. a. List any commercial entities that may be interested in licensing this invention, including contact names if available.

Companies: Contacts: b. List commercial entities, if any, that you specifically do not want contacted regarding this technology and please indicate why.

Companies: Reasons:

6. IDENTIFICATION OF CONTRIBUTOR(S) AND ASSIGNMENT:

3 CONFIDENTIAL I/we hereby 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)

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 ______

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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