Mississippi State University s1

For OTM use only. Software or Work Disclosure #: Copyright Disclosure Form

Instructions: Please complete all applicable sections of the disclosure form and circulate for signatures (including dept heads, deans or directors). The completed form should be forwarded to the Office of Technology Management at Mail Stop 9565. To expedite the review process, please submit an electronic copy by e-mail to [email protected]. For additional assistance, call 662- 325-9263.

1. Principal Developer(s). List the lead developer first. 1. Name: 3. Name: Position: Position: *Dept/Unit: Dept/Unit: Mail Stop: Mail Stop: Phone: Phone: E-mail Address: E-mail Address: Home Address: Home Address: Country of Citizenship: Country of Citizenship: 2. Name: 4. Name: Position: Position: Dept/Unit: Dept/Unit: Mail Stop: Mail Stop: Phone: Phone: E-mail Address: E-mail Address: Home Address: Home Address: Country of Citizenship: Country of Citizenship: *If you have a split appointment, list only the Department, Center or Unit(s) that contributed to your support in the development/research of this technology (for use in distributing department/unit share of any future royalties).

2. Title of Software or Work.

3. Date of Conception/Completion. a. Is there a dated record of the concept - a sketch, report, laboratory notebook entry, etc., that: a) describes your technology, and b) can be independently corroborated? If so, what is it, and where is it?

b. What year was this software/work completed?

4. Publication or Public Disclosure. a. Have you published information about your software/work? If so, please provide details as to the publication, month, date and year when published, and the nation where published. Also, please provide a copy of the publication, if possible.

b. Publication as a contribution. If this work was published as a contribution to a periodical, serial or collection, give information about the collective work in which the contribution appeared (List title and if periodical or serial give volume, number, issue date, and page numbers.)

MSU Software/Copyright Disclosure Form – v1.23.15 1 c. Have you presented any information about your disclosure during any scientific forums, conferences, or other venues? If so, please provide details as to the date, name of the conference, and a copy of your briefing transcript and slides (if any).

d. Have you disclosed this technology to another person? If so, please list their name(s) below.

5. Previous Version of Software or Work. Is there an earlier version of this work? If your answer is “yes,” please complete the following sections as applicable:

a. Previous or alternative titles:

b. Derivative work or compilation. Identify any preexisting work or works that this work is based on or incorporates.

c. Material added to this work. Give a brief, general statement of the material that has been added to this work and in which copyright is claimed.

d. Previous registration. If an earlier version of this work has already been registered in the U.S. Copyright Office, please list registration number and year of registration.

6. Description. What is the software program or work designed to do? Is it primarily a research tool or does it have commercial application. Briefly describe the general nature (examples of the general nature: software, scale model, architectural design, lithographic print, map, photograph, oil painting, technical drawing, logo), primary functions and areas of principal use. Are there any other uses that might be realized with further development?

7. Abstract and Key Words. a. Write a “non-confidential” descriptive abstract describing the software program or work and the purposes for which it can be used. This will be used to market the technology to prospective licensees.

b. List keywords that would be useful in describing your software or work and searching prior art.

8. Specifications. Describe specifications for the software/work, including if applicable:

a. Hardware requirements, third party programs required, or programming language, etc.

b. Was the software/work developed using any pre-existing software/work? Provide details.

c. Was a license agreement provided with the pre-existing software/work described above? Provide a copy if available.

MSU Software/Copyright Disclosure Form – v1.23.15 2 9. Level of Development. a. Has the software/work been tested experimentally? Is it ready for distribution or is further development necessary?

b. Will the software/work require maintenance? If so, what level of support/maintenance (telephone, on-site, etc.) will you and/or your department provide?

c. Stage of Development. How would you characterize the level of development? For software, device, and engineering related technologies, please identify the TRL or “technology readiness level” below (adapted from NASA Technology Readiness Level).

______

____ TRL 1. Basic Research. Basic principles observed and reported.

____ TRL 2. Product Concept. Technology concept and/or application formulated.

____TRL 3. Proof of Concept. Analytical/experimental critical function and/or characteristic proof of concept.

____ TRL 4. Research Prototype. Component and/or breadboard validation in laboratory environment. Examples include integration of “ad hoc” hardware in laboratory to establish they work together. A research prototype with partial functionality; design includes key product elements.

____ TRL 5. Pre-Alpha Prototype. Component and/or breadboard validation in relevant environment. Basic components integrated with reasonably realistic supporting elements. Includes testing that can simulate and validate all system specifications within a laboratory setting.

____ TRL 6. Alpha Prototype. System/subsystem model or prototype demonstration in a relevant environment (alpha prototype). Engineering prototype, ~90% functionality, device in final package or design, reliability testing begun. Functions, looks and feels like the manufactured product.

____ TRL 7. Beta Prototype. System prototype demonstration in an operational environment. Field prototype, fully functional over operational environment, lab tested for reliability, final product design.

____ TRL 8. Final Product. Actual system completed and ‘field qualified’ through test and demonstration.

____ TRL 9. Operational. Actual system 'field proven' through successful mission operations.

10. Commercial Potential. a. How does it differ from other software/work on the market? What problem does it solve or what advantage does it possess?

MSU Software/Copyright Disclosure Form – v1.23.15 3 b. Estimated price range of products: $______. Time to Commercialization: ______Years.

c. Potential # of units that could be sold: ______or overall market value $______

d. What is the biggest obstacle to commercial adoption of the technology?

e. What commercial firms would be, or are, interested in this work? Please provide, if possible, the name and telephone number of a point of contact in each firm.

11. Funding Information. a. Grants and Contracts. Please note that accurate and complete sponsorship information is necessary to fulfill MSU obligations under research grants and contracts.

Was this software/work developed with the use of any research grant/contract funds (include funding from any source in whole or in part)? Yes  No If yes, please provide: Sponsor Grant/Contract Grant/Contract Banner Fund Principal Number Dates Number Investigator

b. Additional Information for MAFES, FWRC and MSU-ES. Was this software/work developed with the use of any appropriated funds (Banner funds 160000, 170000 or 180000)? Yes  No If yes, please provide: CRIS Activity Code or Dates of Activity Indicate project designation (Multi-State, MSU-ES Fund # Hatch, McIntire-Stennis, Smith-Lever, Other)

c. Was this software/work developed outside the university employment of the inventor(s) with no use of university facilities or equipment? Yes  No 

12. Royalty Sharing/Letter of Agreement. Royalty licensing income payable to MSU developers will be distributed among multiple MSU developers in accordance with the Percent Share shown below (i.e. the distribution payable to an MSU individual developer will be calculated by multiplying the Percent Share by the total amount payable to all MSU developers in accordance with the current Policy and Procedure Statement on Intellectual Property at Mississippi State University). Note: Co-developers from outside MSU will be subject to the royalty sharing of their institution. We will contact the other institution and develop an agreement regarding the distribution of any royalties that may result from this technology.

Printed/Typed Name: Printed/Typed Name: *MSU ID #: *MSU ID #: Percent Share: _____% Percent Share: _____% Printed/Typed Name: Printed/Typed Name: *MSU ID #: *MSU ID #: Percent Share: _____% Percent Share: _____% *Please note that the MSU ID number is required; absence of this information may hinder distribution of the inventors’ share of any royalties that may result from this technology. 13. Signatures. Title of Software/Copyright:

MSU Software/Copyright Disclosure Form – v1.23.15 4 The undersigned developer(s) concur with the information contained in this disclosure, hereby assign all title and rights for the software and/or work and improvements herein to Mississippi State University, and hereby agree to the above Percent Share for any licensing income payable to them.

MSU Developer/Creator(s) Witness(es):

______Signature Date Signature Date

______Name of Developer (please type or print) Name and Title of Witness (please type or print)

______Signature Date Signature Date

______Name of Developer (please type or print) Name and Title of Witness (please type or print)

______Signature Date Signature Date

______Name of Developer (please type or print) Name and Title of Witness (please type or print)

Approved (in order):

______Department Head Date

______Dean or Director Date

______University Patent Officer Date

Approved: Royalty Sharing/Letter of Agreement

______Vice President Date