VCOM Institutional Policy and Procedure Manual

Intellectual Property Disclosure

Sponsorship and Agreements Yes No

Was this IP developed with the use of any externally sponsored grant or contract funds (both federal and non-federal)? If Yes, please identify all sponsors below:

Sponsoring Agency

Grant / Contract #

VCOM Fund # Principal Investigator(s)

Yes No

Was IP developed using any VCOM internal funds? If Yes, identify source(s):

Did this IP use any materials obtained from a Material Transfer Agreement or Data Use Agreement? If Yes, please attach copy of MTA or DUA. Have you transferred to any researcher outside of VCOM any new materials related to this IP? Have you entered into any other agreements (MOUs, Consulting, Consortium, etc) that may grant rights of any sort in this IP to a company or party outside VCOM? If yes, please attach.

Determination of Ownership Complete and submit Attachment A: Review for VCOM Ownership then complete the following: Inventor/Originator Owned We do not believe VCOM has any rights or ownership to the intellectual property disclosed. DO NOT SIGN BELOW.

VCOM shall share any royalty income derived from this disclosure according to its Intellectual Properties and Agreements Policy. VCOM inventors must complete Attachment B: Royalty Sharing and Attachment C: Commercial Applications. SIGN BELOW.

VCOM Owned

By signing below, all VCOM originators/inventors agree to assign, and do hereby assign, all right, title and interest to this intellectual property to Edward Via College of Osteopathic Medicine (VCOM) and agree to execute all documents as requested, assigning to VCOM their rights in any patent application or other intellectual property protection filed on this invention, and to cooperate with VCOM in the protection of this intellectual property. By signing below, the originators/inventors confirm that prior to the execution of this disclosure, they have not granted the right or license to make, use or sell the disclosed intellectual property to anyone except to VCOM, nor have they otherwise encumbered their rights, title and interest in the disclosed intellectual property, nor will they execute any instrument in conflict with this agreement. Please note that SIGNATURES ARE INVALID WITHOUT A DATE.

CONFIDENTIAL

VCOM

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