ࡱ> DFC \bjbjޥ .6ǴǴ>rr8 $T'.xx({{{w'y'y'y'y'y'y'$&)+X'\{{\\''$$$\dw'$\w'$$%h7' Oc&c''0's&0, 0, 7'0,7',{L6$,)3{{{''d{{{'\\\\0,{{{{{{{{{r : MSM ID No. ___-_____ CONFIDENTIAL MOREHOUSE SCHOOL OF MEDICINE INVENTION DISCLOSURE Please provide as much information as possible on this form. Attempt to answer all of the questions and be as accurate as you can be, providing as much information as you can to answer the question. If you need more space, use separate pages and attach them to this form. Please feel free to use photocopies of lab notebooks (showing dates), data sheets, drawings or any other rough document(s). If you have questions, please contact the MSM Office for Research Development at 404-752-1050. Title of Invention ________________________________________________________________________ 2. Investigator to whom communications should be addressed. Name: ___________________________________________________________ Address: _________________________________________________________ Phone #: ____________ Fax #: ____________ E-mail: __________________ Date: _____________________________ DESCRIPTION OF THE INVENTION Describe the characteristics/specifications of the invention Please give a complete technical description of the invention and its advantages over what was known previously. If necessary, use drawings, diagrams, pathways, etc. What is the technology that presently exists in the area of this invention? What are the advantages of this technology over existing inventions and practices? What need does this invention meet and how is that need presently being met? What additional embodiments, variations, or applications can you reasonably envision for this invention? Date of the Invention When did you and/or your co-inventors conceive this invention? On or about _____________ Provide the date when a written description was documented in a laboratory notebook, computer record, or other form, other than this Disclosure Form ____________________ DETERMINATION OF OWNERSHIP AND INVESTORSHIP Ownership of the Invention. In my opinion this invention: ___ A. Is owned by MSM in accordance with Patent Policy; ___B. Was developed by the inventor(s) without use of MSM time, facilities, or materials. ___C. Is co-owned by another institution or company. 6. Individuals involved in discovery or inventive contribution. Inventive Contribution is defined as a contribution made to the conception of and/or reduction to practice which would contribute to at least one claim of a patent application. Printed Name in Full _________________________________________ Signature __________________________________________________ Address ____________________________________________________ Phone _____-______ Fax _____-______ E-mail ________________ Date ______________________Citizenship _______________________ Printed Name in Full _________________________________________ Signature __________________________________________________ Address ____________________________________________________ Phone _____-______ Fax _____-______ E-mail ________________ Date ______________________Citizenship _______________________ Printed Name in Full _________________________________________ Signature __________________________________________________ Address ____________________________________________________ Phone _____-______ Fax _____-______ E-mail ________________ Date ______________________Citizenship _______________________ D. Are there additional inventors? Yes _______ No _________ If YES, please list on additional page. Who has funded the development of the invention to date? Grant# _______________ Funding Organization. _____________ P.I._______ Other: Have any agreements been proposed or signed regarding this invention? Yes _____ No _____. If yes, please explain below. Have any materials or facilities which were NOT provided by MSM been used in the discovery or development of this invention? If so, please list the materials and facilities used, who paid for their use, and the approximate dates. Relationship with Third Parties Have you published in any form, including poster material or abstracts, information regarding this invention? If yes, provide details below and attach a copy of each such document. Have you discussed the invention in any non-confidential setting, either in the U.S. or abroad? If so, please give the date of such disclosures, who received the disclosure, the form of the disclosure, e.g., written or oral, and describe the extent of that disclosure, including a description of any materials provided. List any manuscripts which have been prepared and indicate the status of the pending publication(s), e.g., initial review, final review, in press, including possible publication dates. Please attach copies of all such manuscripts. Please list other researchers or organizations of whom/which you are aware might be doing similar work. Cite published references where possible. Provide references to reviews, publications and other literature or public disclosures of this work or any related work of which you are aware. Who would use this product and how would it be used? Please name any competitive products and manufacturers of which you are aware, even though their products are not as good as you invention. List names, addresses, and phone numbers of corporations or individuals you would like to have contacted and who might be interested in licensing this technology. What are your personal goals regarding the development and commercialization of this technology?     CONFIDENTIAL Page  PAGE 3 of  NUMPAGES 6 KLI \  @ Plt#w !#$&')67<=CDEFJKUVWXYZ[\ h]IZh]IZh <mHnHujh]IZUhoTjhoTU hI}>* hI}5\h]IZhI} hI}CJ7#$ABXYH I \ ^ _ ` , - q r   > &d P  & F &d P ^`$a$r  @ A JKL8^8 & F & F LMNOPlmrstoz{ ^`^h^h & F,-jk01no8^8 h^`h^ & Fh^hh`h01pq01pqs#$kltuv & F8^8 h^`h^ & F h^h`vw ^ & F      & F/0123456789nopqrstuvwxyh^h & F      "#%^ hh^h`h & F%&()67YZ[\^$a$gd]IZ$a$gd]IZ ,1h/ =!"#$% ^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nHsH tH@`@ NormalCJ_HaJmH sH tH D@D  Heading 1$$@&a$ 5CJ \D@D  Heading 2$$@&a$ 5CJ$\D@D  Heading 3$$@&a$ 5>*\@@@  Heading 4$$@&a$5\DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 4@4 ]IZHeader  !4 @4 ]IZFooter  !.). ]IZ Page NumberH@"H ]IZ Balloon TextCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] \6 ===@\r Lv%\&(-8:@!8@0(  B S  ?$$.]-44]B*urn:schemas-microsoft-com:office:smarttagscountry-region9*urn:schemas-microsoft-com:office:smarttagsplace=*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName P`p  "#%&()<FJXZ] BW#ox|   "#%&()Z]333333333333333IVmt x mwk "#%&()57<FJX] !"#$%&'()Z]>X5 B!{O0fP~  =|U}Nq^`o(.^`o(.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.^`o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.88^8`o(.^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.hh^h`o(.88^8`.L^`L.  ^ `.  ^ `.xLx^x`L.HH^H`.^`.L^`L.88^8`o(.p0p^p`0o(() L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.>X5U}fP =|!{O 0                 n                 _6J@a       I} <]IZXoT@\@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial5. .[`)TahomaACambria Math"1h{A{AۣxfL (L (142QHP? ]IZ2!xx  MSM ID NoDITS Pitts, Ibn      Oh+'0L    ,4<D MSM ID NoDITSNormal Pitts, Ibn2Microsoft Office Word@@hYg@tO@tOL՜.+,0  hp   School of Medicine(   MSM ID No Title  !"#$%&'()*+,-./012456789:<=>?@ABERoot Entry F` OG1TableP,WordDocument.6SummaryInformation(3DocumentSummaryInformation8;CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q