Invention Disclosure Form

Technology Transfer: Invention Disclosure Form

Fill out our full invention disclosure form below and we will reach out to you to set up a meeting.

If you are looking for the invention short form, access it here.

This is a detailed form that requires a significant amount of information. If you find that you cannot finish it in one sitting, you can scroll to the bottom and hit the "Save & Continue" button. This will save your progress and email you a link so you can complete the form at your convenience. Upon completion, you should receive an email confirming your successful submission. These emails occasionally get directed into the "other" or "junk" email folders, so if you don't receive the notification in your primary inbox, check there. If you have questions, email techtransfer@mines.edu

Name of the person filling out this form.(Required)

First Last

Email for the person filling out this form.(Required)

Please use your Mines email if you have one.

List all Inventors with the PI first.(Required)

Name

Affiliation

Home Address

Are all of the Inventors US Citizens?(Required)

Yes

Please list any Inventors that are not US Citizens and provide infomation on Visa type and status.(Required)

Did you previously fill out the Invention Short Form?(Required)

Yes

Title(Required)

Please provide a title describing your invention.

Invention Summary(Required)

Please summarize the invention and include a non-technical explanation of how it solves a particular problem.

What is the current stage of development?(Required)

Concept Only

Preliminary Data Collected

Proof of Concept Demonstrated

Briefly describe demonstrated proof.(Required)

Has this invention been disclosed to others outside of Mines?(Required)

For example via conversation, poster, conference presentation, manuscript, publication, dissertation/defense, repository submission, etc.

Yes

Describe the desclosure.(Required)

Do you currently have plans to disclose this invention to others outside of Mines within the next three months?(Required)

For example via conversation, poster, conference presentation, manuscript, publication, dissertation/defense, repository submission, etc.

Yes

Decribe disclosure plans and provide dates.(Required)

Was this invention supported by Federal funding?(Required)

Yes

List all federal funding source(s) and agency contract number(s).(Required)

Federal Funding Source/Agency

Agency Contract Number

What do you believe is the most novel aspect of your invention?(Required)

Maximum 500 Characters

Prior Art(Required)

List any prior art that you are aware of that relates to the invention. Please include links to papers, presentations, patents, or other prior art.

Title or Description

Link or Reference

Commercial Potential(Required)

Describe the problem the invention solves, the product(s) envisioned, market(s) in which it could be used, known competitive product(s), and advantage(s) over existing product(s).

Potential Licensee(s)(Required)

List any companies and organizations that might be particularly interested in the invention or that are doing similar research. Provide links or contacts.

Company / Organization

Link or Contact

Conflict of Interest(Required)

Do any of the inventors serve as a director, officer, consultant, board member, or hold financial interest in any of the companies or organizations named above?

Yes

Confict of Interest Description(Required)

Briefly describe the potential conflict of interest and refer to Mines' conflict of interest procedure, which can be found at https://www.mines.edu/compliance/conflict-of-interest/

Is this invention primarily software?(Required)

Yes

Outside Source Material(s)(Required)

Did this invention utilize material(s) obtained for outside of Colorado School of Mines through a material transfer agreement?

Yes

Source Material(s) Description(Required)

Briefly describe the material(s), the source(s), and provide the date(s) of transfer.

Software Documentation(Required)

Please select the button that best describes the software documentation.

No Documentation

Partial Documentation

Full Documentation

Programming Language(Required)

Please identify what programming language was used.

Operating System(Required)

Please identify what operating system is needed for proper functioning of the software.

Application Software(Required)

Please identify what application software is needed for proper functioning of the software.

Application Hardware(Required)

Please identify what hardware is required for proper functioning of the software.

Open Source(Required)

Was any open source code used in the software?

Yes

Open Source Resource(Required)

Please provide information of the source and the open source license that was used.

Interface(Required)

Does the software have a graphical user interface?

Yes

Customization(Required)

Is this software off-the-shelf or does it have to be customized for use for each customer?

Support(Required)

Do you anticipate the customer would need on-going maintenance and support?

Yes

Required Support or Maintenance Description(Required)

Please explain the support or maintenance needed.

Location(Required)

Where is the source code located?

Additional Information

Please include any additional information that will help in evaluating and commercializing this invention.

Documents

If you have any supporting documentation, please upload it here.

Drop files here or

Accepted file types: doc, docx, pdf, ppt, pptx, Max. file size: 250 MB.

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