New Technology Disclosure (Word)

Office for Innovation Development and Commercialization State University of New York at Albany ES 244 1400 Washington Avenue Albany, New York 12222-0100 518 442 3270 fax 518 442 3350

NEW TECHNOLOGY DISCLOSURE

Please submit completed form to the Office for Innovation Development and Commercialization.

1. Title 2. Key Words 3. Type Algorithm Data Design Invention select one Specialized Material/Biological Material Software (must complete Software Addendum) Trademark Work of Authorship (e.g., text, audio, video, photo, musical composition, etc.) Other:

4. Primary Contact (among developers/inventors) 5. Date of Conception

6. Sponsorship United States Government New York State Government Private Industry Research Foundation for SUNY SUNY Personal None Other:

Please provide names of all sponsors below along with related RF/SUNY Account numbers & sponsors’ grant numbers. Research Foundation or Campus Account Number(s) Sponsor-Assigned Name of Sponsor(s) (Project/Task/Award) Identification Number(s)

7. Public Disclosure a. Has the description of Yes No Date: the technology been published? Has the description of Yes No Date: the technology been submitted for publication? Title of publication: Title of journal/other (specify): b. Has the technology Yes No Date: been presented at a

F183-302 - 1 - Revised 6/17/2015 Case No. ______

conference/professional meeting? Title of presentation: Title of conference/professional meeting: Attach copies of any submitted manuscripts, publications, posters, and/or presentations disclosing the technology. 8. Brief Technical Confidential Description (including its unique features) Attach any manuscripts, reviews, papers, diagrams, charts, etc.

9. Prototypes and/or Samples a. Is a working prototype Yes No N/A available for demonstration? b. Are samples (e.g., Yes No N/A compounds) available for testing? 10. Advantages of the Technology (relative to existing technology)

11. Possible Disadvantages of the Technology (relative to existing technology)

12. Non-confidential Description of the Technology (indicate applications and advantages – for marketing purposes)

13. Marketing Targets List companies that you believe would be interested in commercializing the technology. (if any) Company Name Contact Name/Position Phone/Email Location/Address

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14. Signed by Developer(s) and Witness(es) a. Name: Suffix: e.g., PhD, MD Title: Department: UAlbany Yes No If no, Employer: Faculty/Staff/Stud ent? Campus Address: Home Address: Street Address, Apt. # City, ST ZIP00 Campus Phone: Home Phone: Campus Fax: Home Email: Campus Email: Country of Citizenship:

Developer’s Date: Signature:

Witness’s Date: Signature:

b. Name: Suffix: e.g., PhD, MD Title: Department: UAlbany Yes No If no, Employer: Faculty/Staff/Stud ent? Campus Address: Home Address: Street Address, Apt. # City, ST ZIP00 Campus Phone: Home Phone: Campus Fax: Home Email: Campus Email: Country of Citizenship:

c. Name: Suffix: e.g., PhD, MD Title: Department: UAlbany Yes No If no, Employer: Faculty/Staff/Stud ent? Campus Address: Home Address: Street Address, Apt. # City, ST ZIP00 Campus Phone: Home Phone: Campus Fax: Home Email: Campus Email: Country of Citizenship:

d. Name: Suffix: e.g., PhD, MD Title: Department:

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UAlbany Yes No If no, Employer: Faculty/Staff/Stud ent? Campus Address: Home Address: Street Address, Apt. # City, ST ZIP00 Campus Phone: Home Phone: Campus Fax: Home Email: Campus Email: Country of Citizenship:

Witness’s Date: Signature: (Attach additional sheets if there are more than four developers.)

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Software Addendum Please respond to each item, even if the answer is “None” or “Don’t know.”

Add1. What does this software (“the Subject Software”) accomplish?

Add2. Describe the circumstances that led to development of the Subject Software.

Add3. Identify any non-software knowledge resources that were used in developing the Subject Software. (E.g., subject matter experts, scientific or engineering literature resources, etc.)

Add4. What, if any, pre-existing software from other sources (including any open source code) have you incorporated into the Subject Software? In each instance, describe the pre-existing software component and what function it serves, identify its source, and attach the relevant license or other permission allowing you to use the pre-existing software.

Add5. Approximately what percentage of the Subject Software is new code vs. pre-existing code as identified in item Add4 above? 0% Add6. Give the names, affiliations, and titles of all who were involved in the design of the Subject Software.

Add7. Give the names, affiliations, and titles of all who were involved in writing the code for the Subject Software.

Add8. Please identify any linked content. If linked content is used, please identify and provide the license(s) for such content.

Add9. To your knowledge have any copyrights been registered (or registrations been applied for) for the Subject Software or any portions of the Subject Software (including the pre-existing content identified in item Add3 above)? Yes No

If so, please give the title(s) and copyright owner(s) if you know them.

Add10. Identify any grants or contracts which funded any phase of development of the Subject Software. Please include name of institution/company which provided the funds, their reference number, and related Research Foundation/SUNY reference numbers.

Add11. Identify any University space or equipment that were used, or University employees or students that were involved in development of the Subject Software.

Add12. Has the Subject Software been described in any publication or public presentation? Yes No

Has any portion of the Subject Software been published? Yes No

If so, please attach the publication(s)/presentation(s) and indicate the date(s) of publication/presentation.

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Add13. Has the Subject Software, or any portion thereof, or the right to use the Subject Software, been provided to any person or organization that is not part of SUNY or The Research Foundation for SUNY? Yes No

If so, identify the recipient/user and describe how they use(d) the Subject Software.

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