Report an Innovation

Confidential

Record of Innovation (ROI) Form

This ROI form is used for disclosing innovations to the UW Center for Commercialization including mechanical devices, materials, software, digital media and copyrighted works.

Please note the following steps to the ROI submission process:

Step 1: Complete and submit your ROI information online using the form below. If needed, you may save your work using the Save feature at the bottom of this form and submit your ROI when completed.

Step 2: After submitting your information online you will be prompted to print a copy of the form to collect the necessary signatures from your contributors.  Forward to the UW Center for Commercialization (Attn: ROI Coordinator) via campus mail (Box 354990).

You will receive a confirmation email within 24 hours of receipt of this electronic ROI. Please reply to this email and attach any additional information such as manuscripts, grant applications or any other materials that help describe the innovation if available. Within two weeks the technology manager assigned to your ROI will contact you.

If you submitted an ROI and you do not hear from us within the above timeframe please contact our office at (206) 543-3970 to speak to the ROI Coordinator.  We look forward to working with you.

For definitions of the fields, click here or click the [?] beside the field name.

Contact Information
 
 *Contact Name: (required) [?]
 *Contact Email Address: (required)
 *Contact Daytime Phone: (required)
Current Department:(required)
 *Contact is a Contributor:(required)
Principal Investigator (PI): [?]
(if different from the Contact Person)


Contributors [?]

Please list all persons who you believe have contributed to the innovation. If primary contributor is different from contact please give primary contributor information here:
 
 
 Name:(required)
  		Email:(required)
 Title:
  		Phone:
 Institution:(required)
     
 Department:(required) [?]
 
 UW NetID:
 deanv
 Employment status during project (check all that apply):
           
 Are there other employment affiliations?
       
 
 
 Name:(required)
  		Email:(required)
 Title:
  		Phone:
 Institution:(required)
     
 Department:(required) [?]
 
 UW NetID:
 
 Employment status during project (check all that apply):
           
 Are there other employment affiliations?
       
 
 
 Name:(required)
  		Email:(required)
 Title:
  		Phone:
 Institution:(required)
     
 Department:(required) [?]
 
 UW NetID:
 
 Employment status during project (check all that apply):
           
 Are there other employment affiliations?
       
 
 
 Name:(required)
  		Email:(required)
 Title:
  		Phone:
 Institution:(required)
     
 Department:(required) [?]
 
 UW NetID:
 
 Employment status during project (check all that apply):
           
 Are there other employment affiliations?
       
 


 *Nature of Innovation:(required)

Title & Description
 
 *Title of Innovation:(required)
Previous or alternative titles used:

 * Description of Innovation: (2000 character limit) (required) [?]
Please describe, to the extent known at this time, the nature, purpose, and operation of the innovation, including physical, chemical, biological or electrical characteristics. After you submit this ROI form you will be given an email address where you may send as attachments manuscripts, grant applications or any other materials that help describe the innovation.
Please describe a brief layperson's description of the function and use of this innovation. After you submit this ROI form you will be given an email address where you may send a copy of the innovation including: source code, CD-ROM with digital matertials, published content or other works such as flow charts of the file structure for software including a description of key modules in the program, funding proposals, and gift letters.
 * Does this innovation relate to other innovations you have disclosed to C4C?(required)
 *If yes, please name those innovations and describe relationship(required)
Have you consulted with a staff person at C4C?
If yes, please enter the name of that person
Computer language and/or proprietary application used to create this software/digital work:
 * Was any software code used in the device or engineering material?(required) Were any outside materials / code used or incorporated in work?(required)
Please identify any open source code, logos, music, images, text, graphics, etc.
 * If software code (source or object) were used, was encryption functionality also added?
(required)
Please identify any encryption capabilities.
 * Will this item and/or technology be controlled by US Export Laws & regulations?
(required)
Please identify Export Control Classification Number (see CFR15 EAR) or Category Number (see CFR22 ITAR)
 * Has any activity leading to this innovation been influenced by previous work performed at the Quellos High Throughput Screening Core?(required)
Please describe the software/digital work process, modules, or structure:
 *Describe when and how this software/digital work was created:(required)


Funding Sources [?]

What sources of funding were used to develop the innovation?

If the innovation was created under a research project receiving funding from a government agency, nonprofit entity, or a commercial interest, you and UW have obligations to report innovations or provide certain rights to the sponsor.

Please indicate the grant/contract number for the project.
 
 Funding Agency:
  		Contract or Grant Number:
 eGC1 Number:
 Project Title:
 
 Grant PI:
  		Project Period Dates:

Please indicate the grant/contract number for the project.
 
 Funding Agency :
  		Contract or Grant Number:
 eGC1 Number:
 Project Title:
 
 Grant PI:
  		Project Period Dates:

Please indicate the grant/contract number for the project.
 
 Department or Fund Name:
  		Award Contract Number:
 eGC1 Number:
 Project Title:
 
 Grant PI:
  		Project Period Dates:

Please indicate the grant/contract number for the project.
 
 Name of Company:
  		Contract or Grant Number:
 eGC1 Number:
 Project Title:
 
 Grant PI:
  		Project Period Dates:

 
 Source:
  		Documentation: [?]
eGC1 Number:
 Project Title:
 
 PI:
  		Date Received:

 
 Source:
  		Documentation: [?]
Date Received:

Please have all relevant funding information available when you meet with your UW Center for Commercialization case manager.


Use of Materials Obtained from External Sources [?]
 
 * Were any proprietary materials from external sources used to generate the innovation?(required)
 
If yes, please indicate:
 
 Material Name:
 Material Provider:
 Was there a Material Transfer Agreement in place?  
Agreement Reference #
 Any known restrictions on use of this material:
 
 


 
Attach any Material Transfer Agreement, Purchase Agreement, or other documents you may have for each material to the hardcopy printout you will submit.


Publication & Public Disclosure [?]

Have you prepared or have you submitted an article, abstract, or other description of the innovation for publication, presentation, or posting on a public website?
 
 Title/Name (required):
 
  *When Publication Expected  Date (required):
          
 URL:
 

 Title/Name:
 
  *When Presentation Expected  Date (required)
          
 URL:
 

 Title/Name:
 
  *When on Website  Date (required):
             
 URL:
 

 Title/Name:
 
  *Expected Timeline       Date (required)
          
 URL:
 

 


Other Comments

Please use this space to provide any additional information you feel is relevant including any business contacts you may have, market interest, expected applications, or other relevant information. (4000 character limit)



Management of the Innovation by the UW Center for Commercialization

For most innovations made by University faculty and staff, UW will be the assignee (owner) and the UW Center for Commercialization will manage all commercialization efforts, including patenting, license negotiation and management, and the distribution of revenues derived from the innovation.

The UW Center for Commercialization staff will use information in this form to help determine the commercialization potential of your innovation, and determine if a patent should be filed.  Important factors include the innovation's stage of development and commercialization potential, the availability of a licensee, and the competitive landscape.  The cost of obtaining patent protection and the novelty, usefulness, obviousness, and public disclosure status of the innovation are also considered.  Note that the UW Center for Commercialization elected to file patents on about one third of the innovations reported in the past five years.



Revenue Distribution

All rights, obligations, and financial interests, if any, pertaining to or derived from the innovation are as determined under University of Washington Policy ("Policy").  For more information about University of Washington Policy regarding innovations please see the Administrative Policy Statement 59.4, and the University of Washington Handbook Vol. 4, Part 5, Chapter 7, Section 1, Paragraph C.  Policy Statements and the UW Handbook are available on the web.

Note that inventors must provide a current address to the UW Center for Commercialization, to ensure proper payment of revenue distributions from licensing -  if you change addresses, please send updated information to uwinvent@u.washington.edu.  The UW Center for Commercialization will divide moneys earned according to a revenue distribution plan agreed to by all contributors.  Contributors are encouraged to work together to develop such a plan.  Absent such a plan, revenues derived from the innovation shall be distributed equally.



 
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