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

Technology Title

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

Technology Description

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

Technology Differentiation

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

Commercial Applications

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

Potential Partners

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

Stage of Development

This includes theoretical proof or simulation

Use of Materials

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.

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

Public Disclosure

Public disclosures include any publications, presentations, poster displays, invited talks, and external discussions not covered under a confidentiality agreement
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.
If you have multiple appointments, enter the one that represents your primary appointment for this disclosure.
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.

Additional Information

Drop a file here or click to upload Choose File
Maximum upload size: 67.11MB

CLICK SUBMIT TO COMPLETE YOUR DISCLOSURE

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