Fillable Printable Confidential Memorandum of Invention
Fillable Printable Confidential Memorandum of Invention
Confidential Memorandum of Invention
CONFIDENTIAL MEMORANDUM OF INVENTION
When completed, return to: Broad Institute Business Development Office • Room 7CC-7047 • (617)714-8180
This is an important document requiring careful attention
ALL QUESTIONS SHOULD BE ANSWERED
(Attach additional pages as needed)
1. I
nventIon
t
Itle
:
2. P
roject
I
nformatIon
:
Broad Program/Platform
Principal Investigator
3. G
eneral
S
ubject
m
atter
(
check
all
that
aPPly
):
a)
Small molecule/compound Database Diagnostic
New use, existing drug Gene/protein sequence Research tool
Improvement of existing drug Biological Materials Algorithm/software
Method/process Other:
b) KEYWORDS c) COMPOUND IDENTIFIERS
4. f
undInG
S
ourceS
:
Please include all sources of funding to any contributor for the research that led to this invention.
US Govt Commercial/Private Broad Personal Other
Name of Sponsor Grant Number Broad Account Number Title
Print Form
CONFIDENTIAL MEMORANDUM OF INVENTION
When completed, return to: Broad Institute Business Development Office • Room 7CC-7047 • (617)714-8180
5. c
ontrIbutorS
:
Please list all individuals who made any contribution to the conception of the invention or reduction of the invention to practice.
NAME &
EMPLOYER E-MAIL – PHONE
HOME ADDRESS –
CITIZENSHIP
CONTRIBUTION
(CHECK ALL THAT APPLY)
Discussions
Lab research
Theory
Provided materials
Assay dev’t
Discussions
Lab research
Theory
Provided materials
Assay dev’t
Discussions
Lab research
Theory
Provided materials
Assay dev’t
Discussions
Lab research
Theory
Provided materials
Assay dev’t
Discussions
Lab research
Theory
Provided materials
Assay dev’t
6. d
eScrIPtIon
of
the
I
nventIon
:
(a) What problem does this invention solve? How was the problem solved in the past? What was the disadvantage to be overcome? If this
invention is better than prior technologies, state the known advantages of the invention.
(b) What is the key concept on which the invention is based? What are the distinguishing novel features of the invention?
CONFIDENTIAL MEMORANDUM OF INVENTION
When completed, return to: Broad Institute Business Development Office • Room 7CC-7047 • (617)714-8180
(c) What are the currently envisioned uses for the invention? Give a detailed description of how to use for each proposed application.
(d) Please include, as appropriate, generic structures and/or ranges of conditions involved, expected primary and secondary therapeutic
indications, and any other products that might be used in combination with your invention.
(e) Please indicate what you believe to be the closest prior art, including patents and publications.
7. d
etaIled
e
xamPleS
and
/
or
d
rawInGS
; c
hemIcal
n
ame
, c
omPound
t
rackInG
n
umber
and
S
tructure
(a) Attach drawings, sketches, flow sheets of syntheses, etc. showing the contemplated scope, and examples of how the invention is
made and operates.
(b) For compounds, attach a sheet showing the chemical name, Compound Tracking Number and structure of any compounds
within the contemplated scope of the invention. For nucleic acid sequences or polypeptides, include sequence listings if available.
8. r
ecord
of
I
nventIon
:
EVENT (APPROXIMATE) DATE
WHERE RECORDED
(Notebook #, page #) BY WHOM
Initial idea
First written description/ diagram
First reduction to practice
9. S
taGe
of
d
eveloPment
:
Concept Initial, promising result Proof of concept In vitro data Animal data
Please describe your plans for this project for the next year (include funding information).
CONFIDENTIAL MEMORANDUM OF INVENTION
When completed, return to: Broad Institute Business Development Office • Room 7CC-7047 • (617)714-8180
10. o
utSIde
t
echnoloGy
:
Please indicate whether any outside technology and/or material was used in the research that led to this invention. Please also indicate
whether the research that led to this invention is covered by any third party agreements. Please attach any relevant agreements.
Third Party Material?
(biological materials, compounds,
vectors, cell lines, reagents, processes,
methodology, natural products, other)
Material:
Source:
MTA?
Y
N (Please explain)
Third Party Software? Source: License:
Sponsored Research Agreement? Parties:
Collaboration Agreement? Parties:
Confidential Disclosure Agreement? Parties:
11. P
ublIcatIonS
and
d
IScloSureS
In
the
f
Ield
:
Please indicate whether any aspect of your invention has been publicly disclosed or used. Please attach any available publications.
Anticipated Presentation?
Y N
Date:
Manuscript Prepared?
Y N
Submission Date:
Article or Abstract
Y N
Journal:
Submission Date:
Print Publication Date:
Online Publication Date:
Oral Disclosure
Y N
Date:
Occasion:
Handouts/written materials?
Y
Thesis
Y N
Presentation Date: Date Shelved:
Press Release
Y N
Date: Publication:
Web Site
Y N
Date: URL:
Discussion with Industry
Representative?
Y N
Location:
Date:
Individuals/Company:
Poster Presentation
Y N
Date: Occasion:
Has invention been used, tested or
offered for sale outside of the Broad?
Y N
Date: Location:
Other?
Y N
12. c
ommercIal
I
ntereSt
:
Please list any companies or commercial contacts that might be interested in this invention. Please also list any products you believe
would be competing products to this invention.
CONFIDENTIAL MEMORANDUM OF INVENTION
When completed, return to: Broad Institute Business Development Office • Room 7CC-7047 • (617)714-8180
13. S
IGnatureS
of
c
ontrIbutorS
:
All contributors employed by the Broad Institute, Inc. (“Broad”) hereby assign all right, title and interest in this invention to Broad and
agree to execute all documents as requested to assign said rights to Broad. All contributors employed by an entity other than Broad assign
their rights pursuant to their own employment agreement or as otherwise agreed upon.
I/We hereby declare all statements made herein are true and complete to the best of my/our knowledge. I/we hereby further agree to
cooperate in securing intellectual property protection and commercialization of the disclosed invention.
Print Name Broad Location/Phone
Signature Date
Print Name Broad Location/Phone
Signature Date
Print Name Broad Location/Phone
Signature Date
Print Name Broad Location/Phone
Signature Date
14. a
uthorIzatIon
:
Principal investigator, if not a named contributor.
Print Name of Supervisor
Signature of Supervisor Date
Supervisor’s comments as to importance and plans for future research:
