THE UNIVERSITY OF THE WEST INDIES

CONFIDENTIAL

INVENTION DISCLOSURE FORM

Assistance can be obtained from the St. Augustine Centre for Innovation and Entrepreneurship (STACIE). Please complete and forward two (2) copies to: St. Augustine Centre for Innovation and Entrepreneurship, St Augustine Campus, Trinidad; Tel.: (868) 662 2002 Ext. 82483 or (868) 224-3722.

1. Title of Invention:

2. Name(s) of Inventor(s):

2.1	Faculty and Department: 

2.2	Addresses: 
		University:

		Residence:

2.3	Citizenship and (Immigration status, where applicable) of Inventor(s): 

2.4	University Status of Inventor(s): 

2.5	Telephone Number(s): 

2.5	Fax Number(s):
2.6	Email:

3. Please describe the Invention, keeping in mind the following: 

a. What is the technological problem (in a product or process) to which your invention provides an answer or improvement? 

b. What are the shortcomings of present solutions to the same problem? 

c. How do you deal with the problem? 

d. In particular, what are the points of difference between your proposal and existing solutions? 

e. Please provide drawings, sketches, photographs, or any data which may help in understanding   the invention. You may attach additional pages.

4. Where was the research undertaken that resulted in this Invention? 

5. Who funded the research from which the Invention originated?

a. The University of the West Indies?

b. An outside sponsor? If so, give the sponsor's name and identify the grant, contract or agreement. Does the latter include any conditions concerning the disclosure or disposition of the Invention? (This question may require assistance from the St. Augustine Centre for Innovation and Entrepreneurship (STACIE)).

6. Please list all researchers (including graduate students and postdoctoral fellows) who are, or have been, involved in the research that resulted in this Invention. 

7. In your opinion, is this invention owned by the Inventor(s)? Consult the University's Policy on Intellectual Property. 

a. If "No", then please explain. 

Signature: _____________________ Date: _______________ 
Signature: _____________________ Date: _______________ 
Signature: _____________________ Date: _______________ 
Signature: _____________________ Date: _______________ 

b. If "Yes", then please consult Paragraph 2.3 of Part II: Inventions of the University’s Policy on Intellectual Property and advise:

(i) I/we wish to submit the invention to the University for the purposes of obtaining a patent or for its commercial exploitation and management under the terms of the University’s Policy on Intellectual Property, Part II: Inventions: YES / NO

or, (ii) I/we request that the invention be appraised by and, if appropriate, assigned to the University under the terms of the University’s Policy on Intellectual Property, Part II: Inventions: YES / NO

I/we have read the University’s Policy on Intellectual Property. 

Signature: ________________ 	Date: _______________ 
Signature: ________________	Date: _______________ 
Signature: ________________ 	Date: _______________ 
Signature: ________________ 	Date: _______________ 

We also agree to the following division of our 50% share of net annual income for this invention: 

Inventor's name: __________ % ___ 	Signature ______________ 	Date __________
Inventor's name: __________ % ___ 	Signature ______________ 	Date __________
Inventor's name: __________ % ___ 	Signature ______________ 	Date __________
Inventor's name: __________ % ___ 	Signature ______________ 	Date __________

TOTAL:             ________50 %

The other 50% will be allocated to the originating Department/Institute, Campus and the University on a pro rata basis according to the affiliation of the Inventors and Paragraph 3 of the relevant Policy.

Should a different arrangement be envisaged, please indicate:

If you have chosen YES to either 7b(i) or (ii), please answer questions 8 to 15. If not, please see items 16 and 17. 

8. Can you provide references in published literature or patents relating to your Invention? If yes, do so. (An attachment can be added as necessary)

9. Has any publication or disclosure to others been made? If so, to whom, when and where? 

In order to be eligible for Patent and some other forms of protection, it is important in many countries that the inventors maintain strict confidentiality about the subject matter of the invention until application has been made to the national patent authorities for protection. 

10. Has the Invention been tested? 

If yes, does a sample or model of your Invention exist? 

If so, is it available for demonstration if patent action is taken? 

In case of biomedical discoveries please indicate, as applicable, the degree to which your invention has been tested in vitro, in vivo, in animal models or humans.

 

11. Are figures, tables, photographs or prints, slides, motion pictures, available?

12. Do you expect to continue work towards improving the apparatus, product or process?

13. Is there within the next six months a meeting of a learned society or deadline of publication of a scientific journal at which you are anxious to make disclosure? If so, when and where? 

14. Can you suggest where or how your apparatus, product or process might be used? If so, please elaborate (an attachment can be added as necessary).

15. Have you been contacted by or are you currently communicating with a company? 

(N.B. The University has standard Nondisclosure Agreements under which the information may be shared on a confidential basis with a potential sponsor for the development of the Invention). Please elaborate. 

16. Inventions wholly owned by the research sponsor under a Research Agreement:
The Inventor(s) should inform the St. Augustine Centre for Innovation and Entrepreneurship (STACIE) of the nature of the invention, its ownership and the proposed disposition of the invention, if known. Please elaborate:

17. Inventions wholly owned by the staff member(s) or student(s):
I/we wish(es) to proceed to obtain patents, negotiate licences, etc., and undertake(s) to fully inform the University on intentions or actions to be taken.

Signature: ___________________________ 	Date: _______________ 
Signature: ________________ ___________	Date: _______________ 
Signature: ________________ ___________	Date: _______________ 
Signature: ________________ ___________	Date: _______________  

N.B. All information reported above will be considered confidential and will be treated as such by the University. The information will be released only through Nondisclosure Agreements with third parties, and with the consent of the inventor(s).