Invention Disclosure Form

1. Title of invention
Type text here.

2. Description of the invention
What is the invention? Which problems do the invention solve? Who are the end-users? Are there other solutions/treatment methods for the problem?	Are there other possible areas of application for the invention? Key aspects of the invention that makes it unique and generates benefits. Possible problems/barriers to the project’s development.
You are welcome to attach an extended electronic version. Type text here.

3. Developmental stage
Describe the invention’s current developmental stage (theoretical concept, in vitro data, in vivo data, clinical data, proof-of-concept, prototype, etc.) Elaborate on your response and attach data for support. Type text here.

4. Documentation of the invention
When did you conceive the invention? Type text here.
Please describe where and how the invention is documented:
Type text here.

5. Publication Please state below whether there is a description of the invention in documents that in any way are in a published form (i.e. an article, submitted protocol, presentation). In case any form of publication has been made, please include date of publication, which media it is and where to retrieve the information (This could give implications for the possibility of patenting the invention.)
Type text here.

6. Grants and cooperation Please indicate if the research has been financed through external sources and if the invention is made as part of a research collaboration.
Has/have the inventor(s) applied for or received research grants related to the invention? If yes, please specify: Type text here. It is very important to attach all relevant documentation
Is the invention part of research collaboration? If so then please state who is the collaborative party. If yes, is the collaboration regulated by agreements? It is very important to attach all relevant documentation

7. Use of information, materials, equipment, etc. from external parties
Is the invention wholly or partially based on information, materials, equipment, software, etc. from other individuals/organisations outside of your hospital/institution?
If yes, please tick all of the relevant boxes below:
Description:	Type of material:	Type of software:
Is this information:
Describe the conditions regarding rights: Type text here.	Type text here.	Type text here.
Were the materials used: Describe the conditions regarding rights: Type text here.	Was the software used: Describe the conditions regarding rights: Type text here.
IMPORTANT: Please attach a copy of all relevant contracts and any other documentation regarding the existence of informal agreements

8. Literature and patent application
Literature
1. Describe relevant keywords and synonyms regarding the invention, in English: Type text here.
2. List other leading researchers (industrial and academic) in the field of the invention: Type text here.
3. If possible, attach own articles, abstracts, and reviews that are relevant to the invention, either as background for the invention or publication of it.
4. If possible, attach any articles, abstracts, and reviews by other parties that are relevant to the invention and other information that you feel may be relevant to an assessment of the invention.

9. Inventors
Contact information, work	Contact information, private (optional)
Inventor 1:
Name: Type text here.	Address: Type text here. E-mail: Type text here. Telephone, private: Type text here. Mobile telephone: Type text here.
Title: Type text here.
Contribution to the invention: Type text here.%
Employed by hospitals or institutions under Region Zealand:
Type (please mark the relevant boxes):
Start date of employment: Type text here.
Hospital/Institution: Type text here. Department: Type text here. Address: Type text here. E-mail: Type text here. Telephone, work: Type text here. Fax: Type text here.	Professor at the University of Copenhagen/SDU:
Date of appointment: Type text here.
Other employment or consultancies relevant for the invention (please specify or attach list): Type text here.
Contact information, work	Contact information, private (optional)
Inventor 2:
Name: Type text here.	Address: Type text here. E-mail: Type text here. Telephone, private: Type text here. Mobile telephone: Type text here.
Title: Type text here.
Contribution to the invention: Type text here. %
Employed by hospitals or institutions under Region Zealand:
Type (please mark the relevant boxes):
Start date of employment: Type text here.
Hospital/Institution: Type text here. Department: Type text here. Address: Type text here. E-mail: Type text here. Telephone, work: Type text here. Fax: Type text here.	Professor at the University of Copenhagen/SDU:
Date of appointment: Type text here.
Other employment or consultancies relevant for the invention (please specify or attach list): Type text here.
If additional inventors please copy and insert this section 9 and provide the requested information

10. Primary contact person
Please list the inventor who Operations, Research and Innovation (and any involved advisors) can contact with general questions about the invention, etc. Type text here.

11. Additional information and comments
Type text here.

Please sign the Invention Disclosure Form on the next page

Signature(s)

Declaration of secrecy It is of utmost importance that there is no publication of the invention in any way before submitting a patent application, as such publication will be detrimental for obtaining patent rights for the invention. All of those involved have a duty of secrecy regarding information related to the invention. By signing this document, the inventor(s) and department management undertakes not to disclose any information regarding the invention to any third party, or in any way deal with the rights to the invention, unless such disclosure or dealing has been agreed with Data and Development Support, Research and Innovation. In case the inventor(s) is notified in writing that, the hospital or psychiatry administration does not wish to assume the rights to the invention in accordance with the Danish act on inventions made at public research institutions, the inventor(s) is no longer obligated by this declaration of secrecy.

Signature: _____________________	Signature: ____________________

Date: __________	Date: __________

(dd/mm/yyyy)	(dd/mm/yyyy)

Signature: _____________________	Signature: ____________________

Date: __________	Date: __________

(dd/mm/yyyy)	(dd/mm/yyy)

Department manager

Signature: ____________________

Date: __________

(dd/mm/yyyy)

Department manager and all of the persons listed in section 9 must sign above. Please send the signed original and completed form to: Data and Development Support Attn.: Head of Research & Innovation Region Zealand Alleen 15 4180 Sorø

For internal use by Data and Development Support, Research and Innovation:

Date received: Signed on behalf of Data and Development Support ____________________ ___________________________ (dd/mm/yy)