IPC-Invention Disclosure Form

Confidential MUSC Record of Invention (ROI) Form

This Disclosure is made in accordance with the MUSC Intellectual Property Policy effective July 1, 2008, which can be found at http://frd.musc.edu/.

Inventor(s): Inventors are those who made an intellectual contribution to the invention. Not all authors on a manuscript are necessarily Inventors. Inventorship is determined by the prosecuting patent attorney. As a result, Inventors listed on this Record of Invention Form may not meet the legal requirements necessary to qualify as an Inventor.

Please check which Inventor will be the Corresponding Inventor. Unless otherwise requested in writing or otherwise required by law, the Corresponding Inventor shall be considered the point of contact between the MUSC Foundation for Research Development and the Inventors as a group and will receive all correspondence on behalf of all the Inventors. Please list all Inventors including those at other institutions. Additional Inventors can be listed on the final page, if needed.

1. Detailed Information on Inventors:

Inventor #1 Inventor #2 Inventor #3 Name Position Department MUSC Campus Mailing Address MUSC Office Location E-mail Address Work Telephone Home Address Home Telephone Citizenship “X” by Corresponding Inventor

2. Title of Invention:

Revised October 2008 Page 1 of 9 FRD File No.: ______Confidential MUSC Record of Invention (ROI) Form

3. Brief Description of Invention: Please summarize your invention describing the unique characteristics and advantages over existing technology . Use plain paper if more space is needed. Please attach descriptive material (manuscripts, slides, abstracts, diagrams, data, etc.) if available.

4. Dates and Records: a.) When did you first conceive of this discovery?

b.) Do you have laboratory records and data? Yes No If Yes, do not enclose, but give reference and physical location.

c.) Have your records been witnessed? Yes No

5. Export Controls and Select Agents: a.) Is this invention, or the information or materials related to this invention, subject to export controls? Yes No Unsure  If Yes or Unsure, contact the Director of the Office of Research and Sponsored programs PRIOR to submitting this ROI to FRD.

ORSP Signature: ______Date: ______

b.) Were any select agents used or produced in the research? (see “List of Select Agents and Toxins” available at http://www.cdc.gov/od/sap/index.htm) Yes No Unsure  If Yes or Unsure, obtain approval of the Director of the Office of Research and Sponsored programs PRIOR to submitting this ROI to FRD.

ORSP Signature: ______Date: ______

6. Disclosures: With regard to work related to the invention, have you or do you plan to (if yes, add details below): a.) present? Yes No  Presentation date: • Where?  Expected publication date of Abstract or other poster/documents (incl. on-line): b.) publish? Yes No  Submission date: • Where?  Expected publication date (incl. e-pub): c.) describe in a grant application? Yes No  Submission date:  Has this grant been funded? Yes No  Date funded: d.) disclose to any company? Yes No  Disclosure date:  If disclosed, was a Confidentiality Agreement signed? Yes No e.) otherwise disclose (e.g. to co-authors that are not co-inventors)? Yes No  Disclosure date: • If disclosed, was a Confidentiality Agreement signed? Yes No  If no Confidentiality Agreement, was there an expectation of Confidentiality? Yes No

If Yes to any of a-e, provide details of presentation/publication including any citations and attach relevant documentation, as well as the circumstances of any disclosure, such as to whom (name & address) and where:

7. Consulting, CoEE, or Other Appointments: a.) Do you have a Consulting Agreement with any company that relates to this technology? Yes No  Company name & address: b.) Do you have an appointment at the VA (WOC, DAP, or other)? Yes No  What and when is appointment effective? c.) Are you a CoEE Chair holder or performing research as part of a CoEE? Yes No If Yes to any a-c, list details for each applicable Inventor.

d.) Do you have an appointment at another institution? Yes No • What type of appointment and institution?

8. Utility: a.) What are the possible uses of the invention (e.g. diagnostic, screen, therapeutic, device)? Please explain:

b.) What is the stage of development? Do you have in vitro or in vivo data, or clinical data? If applicable, do you have a prototype? Describe in detail (include number of times repeated, etc.)

c.) What further research and development is necessary before your invention can be used by the public? (Include all steps, even if they can/will not be done at MUSC)

d.) What experiments are planned for the further development/commercialization of the invention and/or for research in areas related to the invention? What funding source do you expect to use for these experiments?

9. Non-obviousness: What are the other known technologies/therapies/methods and how does the invention provide an improvement over other technologies? If known, give reference(s).

10. Ownership: a.) For Employee (including Faculty and Staff) Inventors: 1) Was this invention conceived of or reduced to practice while employed at MUSC? Yes No 2) Is this invention in the field in which you are engaged by MUSC? Yes No 3) Was this invention made with the use of University Resources? (see IP Policy Section 6.1) Yes No If No to any 1-3, please explain:

b.) Student Inventors:  Was the invention created, conceived or reduced to practice (a) during the course of research conducted at MUSC; (b) through the use of University Resources; (c) in conjunction with one or more persons who are otherwise obligated to assign their rights in such Intellectual Property to MUSC under the MUSC IP Policy; or (d) under terms of an MUSC contract with a third party which provide for disposition of the Intellectual Property? (See IP Policy Section 6.2) Yes No If No, please explain:

c.) Visiting Inventors:  Was this invention created through the use of University Resources? (See IP Policy Section 6.3) Yes No If No, please explain:

d.) Were any of the materials used in the research obtained under a Material Transfer Agreement (MTA) or purchased under a contract that might restrict their use? Yes No  Company name (attach copy of MTA/Contract):

11. Other Contributions: Did any other University Staff contribute to the invention? Yes No Briefly describe:

12. Funding: Note it is critical that proper funding sources be identified. Failure to properly identify proper funding could result in a loss of rights to your discovery. a.) Federal Funding: Was Federal funding used to support the conception or first actual reduction to practice of the invention? If Yes, list Sponsor Name, Grant/Contract No., and PI Name below. Yes No

b.) List all other sources of funding, including corporate or foundation used for the conception or actual reduction to practice of the invention. Include Sponsor Name, date of funding Agreement, and PI Name below.

13. Commercial Interest: a.) Has any company shown an interest in the invention? Yes No  Name and phone number of company and contact:

b.) Do you have any suggestions of companies that may be interested? If so, please list and provide contact information if known:

14. Inventor(s) Income Sharing Agreement: Is there a written agreement among the Inventors which provide for other than equal division of proceeds among the Inventors? Yes No (If yes, please attach copy of agreement to ROI)

15. Reference materials: Please list other pertinent articles, presentations or other public disclosures, made by you or by other researchers, which are related to your invention or discovery. This would include earlier disclosures of the general concepts related to this invention. Attach copies please.

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16. Signatures: a.) Inventors: I attest that the information contained herein is accurate and complete.

Inventor Signatures Date Witness Signatures Date

b.) Supervisor's Endorsement: This section will normally be completed by the Department Chairman for each Inventor. However, in circumstances where a Department Chairman is also an Inventor, the Department Chairman’s Supervisor must complete this section.

I have reviewed the information provided above with particular reference to Items 9-11, which addresses resources and the source of funds contributing to the invention. To the best of my knowledge, I believe the above statement(s) to be accurate.

Signature: Date:

Supervisor Name Typed: Title:

Signature: Date:

Date Received by the MUSC Foundation for Research Development:

Additional Inventors (if needed):

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