CONFIDENTIAL IDEA DISCLOSURE Please download this form before completing it.

The Commonwealth Commercialization Center (C3) is a science and technology nonprofit that is the Kentucky flagship for supporting and accelerating invention, innovation and entrepreneurship across the state. C3 serves as a vehicle for partnerships with public Kentucky universities and colleges in an effort to transition ideas and intellectual property into products and businesses through investment.

This form is for use by faculty, staff and students of C3 partner universities and colleges that have executed the Commonwealth Commercialization Center Participating Institution Collaboration Agreement ("Collaboration Agreement"). Before beginning, please confirm your institution's participation and access more information by visiting c3kentucky.com.

Once thoroughly completed, please submit this form and all related abstracts, drawings, manuscripts, etc. via email to ideadisclosure@c3kentucky.com.

Information herein is submitted for purposes of seeking advice concerning patentability, copyrightability, etc. Such information is subject to review and confirmation.

Date:

For C3 use:

C3 receipt acknowledgment:

C3 disclosure number:

TECHNOLOGY DETAILS

Title of the technology:

Description of disclosure: Please provide a detailed description of the technology, containing sufficient detail of the technology so that one skilled in the same discipline as yourself could reproduce the technology. Include materials and components used; operative and preferred ranges of process parameters and concentration of chemical compounds; and foreseeable uses of the technology. Supplemental materials, such as publications, protocol, presentations or images may be included/attached when the form is submitted.

CONFIDENTIAL IDEA DISCLOSURE What is the problem the technology addresses? What commercial applications could it have?

SIMILAR EXISTING INFORMATION

Are you familiar with any information in print or products that are similar to the technology disclosed within? ⃝ Yes ⃝ No If yes, please provide the full title and citation and/or details and links if available:

CONCEPTION DETAILS

Fill in the following dates (if known) Conception (month/day/year): First experiment demonstrating the technology (month/day/year):

FUNDING

Was the technology conceived or first actually reduced to practice in the performance of work funded, in whole or in part, by any federal grant(s), contract(s) or subcontract(s)? ⃝ Yes ⃝ No If yes, list below.

CONFIDENTIAL IDEA DISCLOSURE

Funding institute(s)/sponsor(s):

Grant/contractnumber(s):

Issue date: Principal investigator:

PUBLICATION & PUBLIC DISCLOSURE

Has the technology been publicly disclosed in any manner? Examples of public disclosure include, but are not limited to, publication in a journal or on a website, poster session, conference presentation, lecture, video production, social media posting and products being offered for sale. Please list all public disclosures of this technology and the date of the activity.

Do you intend to publish or publicly disclose the technology in the future? Please list all planned public disclosures of this technology and the anticipated date of the activity.

Note: Non-confidential disclosure of a technology (to anyone outside of your university/college) may initiate a one-year period within which a United States patent application may be filed. If an application is not filed in this time, U.S. law prevents one from obtaining patent protection of the disclosed technology. The patent laws of other countries are even more strict: In generally, the right to patent protection is lost immediately upon public disclosure unless a U.S. patent application is filed prior to such disclosure. Please keep your respective university or college and the Commonwealth Commercialization Center informed of any future possible public disclosure.

Will any federal sponsoring entity be acknowledged if information related to this technology is published or disseminated to the scientific community? Yes No If yes, list below.

Grant/contract number(s):

Funding institute(s)/ sponsor(s):

CONFIDENTIAL IDEA DISCLOSURE

COMMERCIAL POTENTIAL

Has any commercial entity inquired or expressed interest in this technology? If so, please list the entity and any personal contacts you have at the entity:

Is there a competitive technology currently available on the market? Please name and describe the technology:

If there is a competitive technology currently available on the market, how does your technology differ from and/or offer an advanced application than the existing technology? What sets your technology apart from what’s available on the market?

CONFIDENTIAL IDEA DISCLOSURE

CONTRIBUTOR'S INFORMATION

Please provide information for all individuals believed to have contributed to the conception or creative reduction to practice of this disclosure, with one contributor listed per page. Please note that inventorship is subject to legal review. For each contributor, please provide the following information for when this research was conducted:

First name Middle name Last name University College Department Citizenship Work phone numbers Work email address Other email address Home address City State Zip code Cell phone number

Provide the details of this individual’s contribution to the technology:

Submission acknowledgment:

Contributor’s signature: Date:

I submit this Confidential Idea Disclosure pursuant to my applicable college or university (the “Institution”) intellectual property policy (the “Policy”). Pursuant to such Policy, I hereby agree to assign, and do hereby assign, to my Institution, all my rights, title and interest in any intellectual property described herein. I also agree to provide reasonable assistance and cooperation to C3 and/or my Institution to protect and develop the commercial value of this idea. Any monetary proceeds that my Institution receives for this idea will be distributed according to the Policy. I understand that if C3 and/or my Institution decide(s) not to seek protection for the idea, provided that I have met the obligations under the Policy with respect to disclosure of the idea and appropriate cooperation, my Institution will release its rights in the idea as it has been disclosed. I understand that any advancement or alteration made to the idea after the date of this Idea Disclosure will need to be submitted to my Institution for review pursuant to the Policy. Notwithstanding the foregoing, any release of rights in the idea may be subject to applicable restrictions or requirements imposed by the terms of any grant, contract or cooperative agreement to which the research/development is a party, or as imposed by applicable law, rule or regulation.