Sample Online Technology Disclosure Form | Precision Technology Consulting

Online Technology Disclosure

Sample Online Technology Disclosure Form

This is a sample online technology disclosure form, intended for demonstration purposes only. NONE of the information entered into this form is stored, it is deleted immediately upon exit. If you would like to see how the form data is exported, you can enter your email in the first section and a summary of the form data will be sent to your email upon submission. Again, NONE of this data is saved at any point.

Online Technology Disclosure Form

To Recieve a Copy of the Form Data

If you would like to receive a copy of the form data, enter your email here. Neither your email nor your form data is saved, this is purely for demonstration purposes.

Technology Title

Title of Technology *

Provide a short title to refer to your technology (no more than 5 words)

Technology Description

Provide a complete description of the technology *

If you need to attach additional documents, you may do so via the drag & drop plugin at the bottom of this page

Technology Differentiation

Explain in detail the current state of the art, and how your technology is differentiated

If you need to attach additional documents, you may do so via the drag & drop plugin at the bottom of this page

Commercial Applications

Describe the commercial applications for this technology

If you need to attach additional documents, you may do so via the drag & drop plugin at the bottom of this page

Potential Partners

List any company/industry contacts that would be interested in this technology

Provide as much detail as possible, include email addresses and phone numbers if available

Stage of Development

Has this technology been reduced to practice?

Yes

Are labratory records and data available?

Yes

Has the technology been theoretically demonstrated?

Yes

This includes theoretical proof or simulation

Use of Materials

Have any materials been used from external parties?

Yes

You should answer yes if materials have been used in the conception or development of this technology that would be covered under a material transfer agreement with a third party. Anything purchased (i.e. 'off-the-shelf items') would generally not be included.

Provide any details of the materials and/or material transfer

Funding Status

Please give details of any funding that led to the conception and/or development of the technology. If no funding was utilized, you must select NO FUNDING WAS UTILIZED in the dropdown below.

Type of Funding *

Funding Entity

List the name of the funding entity (company, agency, etc...)

Contract or Grant Number

Was there a second funding entity?

Yes

Type of Second Funding Entity

Second Funding Entity

List the name of the funding entity (company, agency, etc...)

Second Contract or Grant Number

Were there any additional funding entities?

Yes

Public Disclosure

Have you made any public disclosures of the technology *

Yes

Public disclosures include any publications, presentations, poster displays, invited talks, and external discussions not covered under a confidentiality agreement

Provide details of any and all public diclosures

List the EXACT date of the FIRST public disclosure

What is your first anticipated public disclosure

What is the EXACT date of your first anticipated disclosure

Be as specific as possible

Contributor

The first named contributor should be the individual that will be the primary contact for all communications regarding management of this technology. This designation does not convey any contribution 'weight,' it is just the person who will be the primary contact.

First Name *

Middle Name

Last Name *

Position/Classification * Position/Classification

College/Center/Institute Appointment *

If you have multiple appointments, enter the one that represents your primary appointment for this disclosure.

Department *

Additional Appointments

List any other appointments relevant to the conception and/or development of this technology and include the percentage time of the other appointment. If you do not have any other relevant appointments, leave this section blank.

Telephone (work) *

Telephone (cell)

Email *

Is there a second contributor? *

Yes

Second Contributor - First Name

Second Contributor - Middle Name

Second Contributor - Last Name

Second Contributor - Position/Classification Second Contributor - Position/Classification

Second Contributor - College/Center/Institute Appointment

Second Contributor - Department

Second Contributor - Additional Appointments

Second Contributor - Telephone (work)

Second Contributor - Telephone (cell)

Second Contributor - Email

Are there other contributors?

Yes

Additional Information

It is possible to include a plugin to allow uploading of additional documents (PDF, Word, PowerPoint, Excel, etc...)

CLICK SUBMIT TO COMPLETE YOUR DISCLOSURE

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Online Technology Disclosure

To Recieve a Copy of the Form Data

Technology Title

Technology Description

Technology Differentiation

Commercial Applications

Potential Partners

Stage of Development

Use of Materials

Funding Status

Public Disclosure

Contributor

Additional Information

CLICK SUBMIT TO COMPLETE YOUR DISCLOSURE

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