Confidential
MUSC Record of Invention (ROI) Form
This Disclosure is made in accordance with the MUSC Intellectual Property Policy effective July 1, 2008,
which can be found at http://frd.musc.edu/.
Inventor(s): Inventors are those who made an intellectual contribution to the invention. Not all authors on a
manuscript are necessarily Inventors. Inventorship is determined by the prosecuting patent attorney. As a
result, Inventors listed on this Record of Invention Form may not meet the legal requirements necessary to
qualify as an Inventor.
Please check which Inventor will be the Corresponding Inventor. Unless otherwise requested in writing or
otherwise required by law, the Corresponding Inventor shall be considered the point of contact between the
MUSC Foundation for Research Development and the Inventors as a group and will receive all correspondence
on behalf of all the Inventors. Please list all Inventors including those at other institutions. Additional
Inventors can be listed on the final page, if needed.
1. Detailed Information on Inventors:
Inventor #1
Inventor #2
Inventor #3
Name
Position
Department
MUSC Campus Mailing Address
MUSC Office Location
E-mail Address
Work Telephone
Home Address
Home Telephone
Citizenship
“X” by Corresponding Inventor
2. Title of Invention:
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3. Brief Description of Invention: Please summarize your invention describing the unique characteristics and
advantages over existing technology . Use plain paper if more space is needed.
Please attach descriptive material (manuscripts, slides, abstracts, diagrams, data, etc.) if available.
4. Dates and Records:
a.) When did you first conceive of this discovery?
b.) Do you have laboratory records and data?
Yes
No
If Yes, do not enclose, but give reference and physical location.
c.) Have your records been witnessed?
Yes
No
5. Export Controls and Select Agents:
a.) Is this invention, or the information or materials related to this invention, subject to export controls?
Yes
No
Unsure
If Yes or Unsure, contact the Director of the Office of Research and Sponsored programs PRIOR to
submitting this ROI to FRD.
ORSP Signature: __________________________________ Date: _______________
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b.) Were any select agents used or produced in the research? (see “List of Select Agents and Toxins” available
at http://www.cdc.gov/od/sap/index.htm)
Yes
No
Unsure
If Yes or Unsure, obtain approval of the Director of the Office of Research and Sponsored programs
PRIOR to submitting this ROI to FRD.
ORSP Signature: __________________________________ Date: _______________
6. Disclosures:
With regard to work related to the invention, have you or do you plan to (if yes, add details below):
a.) present?
Yes
No
• Where?
Presentation date:
Expected publication date of Abstract or other poster/documents (incl. on-line):
b.) publish?
Yes
No
Yes
No
Yes
No
Yes
No
• Where?
Submission date:
Expected publication date (incl. e-pub):
c.) describe in a grant application?
Submission date:
Has this grant been funded?
Date funded:
d.) disclose to any company?
Disclosure date:
If disclosed, was a Confidentiality Agreement signed?
Yes
No
e.) otherwise disclose (e.g. to co-authors that are not co-inventors)?
Disclosure date:
• If disclosed, was a Confidentiality Agreement signed?
If no Confidentiality Agreement, was there an expectation of Confidentiality?
Yes
Yes
Yes
No
No
No
If Yes to any of a-e, provide details of presentation/publication including any citations and attach relevant
documentation, as well as the circumstances of any disclosure, such as to whom (name & address) and where:
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7. Consulting, CoEE, or Other Appointments:
a.) Do you have a Consulting Agreement with any company that relates to this technology?
Yes
No
Company name & address:
b.) Do you have an appointment at the VA (WOC, DAP, or other)?
Yes
No
What and when is appointment effective?
c.) Are you a CoEE Chair holder or performing research as part of a CoEE?
Yes
No
If Yes to any a-c, list details for each applicable Inventor.
d.) Do you have an appointment at another institution?
Yes
No
• What type of appointment and institution?
8. Utility:
a.) What are the possible uses of the invention (e.g. diagnostic, screen, therapeutic, device)? Please explain:
b.) What is the stage of development? Do you have in vitro or in vivo data, or clinical data? If applicable, do
you have a prototype? Describe in detail (include number of times repeated, etc.)
c.) What further research and development is necessary before your invention can be used by the public?
(Include all steps, even if they can/will not be done at MUSC)
d.) What experiments are planned for the further development/commercialization of the invention and/or for
research in areas related to the invention? What funding source do you expect to use for these experiments?
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9. Non-obviousness:
What are the other known technologies/therapies/methods and how does the invention provide an improvement
over other technologies? If known, give reference(s).
10. Ownership:
a.) For Employee (including Faculty and Staff) Inventors:
1) Was this invention conceived of or reduced to practice while employed at MUSC?
Yes
No
2) Is this invention in the field in which you are engaged by MUSC?
Yes
No
3) Was this invention made with the use of University Resources? (see IP Policy Section 6.1)
Yes
No
If No to any 1-3, please explain:
b.) Student Inventors:
Was the invention created, conceived or reduced to practice (a) during the course of research conducted
at MUSC; (b) through the use of University Resources; (c) in conjunction with one or more persons who
are otherwise obligated to assign their rights in such Intellectual Property to MUSC under the MUSC IP
Policy; or (d) under terms of an MUSC contract with a third party which provide for disposition of the
Intellectual Property? (See IP Policy Section 6.2)
Yes
No
If No, please explain:
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c.) Visiting Inventors:
Was this invention created through the use of University Resources? (See IP Policy Section 6.3)
Yes
No
If No, please explain:
d.) Were any of the materials used in the research obtained under a Material Transfer Agreement (MTA) or
purchased under a contract that might restrict their use?
Yes
No
Company name (attach copy of MTA/Contract):
11. Other Contributions:
Did any other University Staff contribute to the invention?
Yes
No
Briefly describe:
12. Funding:
Note it is critical that proper funding sources be identified. Failure to properly identify proper funding could
result in a loss of rights to your discovery.
a.) Federal Funding: Was Federal funding used to support the conception or first actual reduction to practice of
the invention? If Yes, list Sponsor Name, Grant/Contract No., and PI Name below.
Yes
No
b.) List all other sources of funding, including corporate or foundation used for the conception or actual
reduction to practice of the invention. Include Sponsor Name, date of funding Agreement, and PI Name below.
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13. Commercial Interest:
a.) Has any company shown an interest in the invention?
Yes
No
Name and phone number of company and contact:
b.) Do you have any suggestions of companies that may be interested? If so, please list and provide contact
information if known:
14. Inventor(s) Income Sharing Agreement:
Is there a written agreement among the Inventors which provide for other than equal division of proceeds
among the Inventors?
Yes
No
(If yes, please attach copy of agreement to ROI)
15. Reference materials:
Please list other pertinent articles, presentations or other public disclosures, made by you or by other
researchers, which are related to your invention or discovery. This would include earlier disclosures of the
general concepts related to this invention. Attach copies please.
[SIGNATURE PAGE FOLLOWS]
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16. Signatures:
a.) Inventors: I attest that the information contained herein is accurate and complete.
Inventor Signatures
Date
Witness Signatures
Date
b.) Supervisor's Endorsement: This section will normally be completed by the Department Chairman for each
Inventor. However, in circumstances where a Department Chairman is also an Inventor, the Department
Chairman’s Supervisor must complete this section.
I have reviewed the information provided above with particular reference to Items 9-11, which addresses
resources and the source of funds contributing to the invention. To the best of my knowledge, I believe the
above statement(s) to be accurate.
Signature:
Date:
Supervisor Name Typed:
Title:
Signature:
Date:
Supervisor Name Typed:
Title:
Signature:
Date:
Supervisor Name Typed:
Title:
Date Received by the MUSC Foundation for Research Development:
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Additional Inventors (if needed):
Inventor #4
Inventor #5
Inventor #6
Inventor #7
Inventor #8
Inventor #9
Name
Position
Department
MUSC Campus Mailing Address
MUSC Office Location
E-mail Address
Work Telephone
Home Address
Home Telephone
Citizenship
“X” by Corresponding Inventor
Name
Position
Department
MUSC Campus Mailing Address
MUSC Office Location
E-mail Address
Work Telephone
Home Address
Home Telephone
Citizenship
“X” by Corresponding Inventor
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