Revised Form 1679

National Aeronautics and Space Administration

Disclosure of Invention and New Technology (Including Software)

Form Approved O.M.B. NO. 2700-0009

DATE      

CONTRACTOR CASE NO.      

This is an important legal document. Carefully complete and forward to the Patent Representative (NASA in-house innovation) or New Technology Representative (contractor/grantee innovation) at NASA. Use of this report form by contractor/grantee is optional; however, an alternative format must

NASA CASE NO. (OFFICIAL USE ONLY)      

at a minimum contain the information required herein. NASA in-house disclosures should be read, understood and signed by a technically competent witness in the witness signature block at the end of this form. In completing each section, use whatever detail deemed appropriate for a “full and complete disclosure.” Contractors/Grantees please refer to the New Technology or Patent Rights – Retention by the Contractor clauses. When necessary, attach additional documentation to provide a full, detailed description.

DESCRIPTIVE TITLE      

INNOVATOR(S) (For each innovator provide: Name, Title, Work Address, Work Phone Number, and Work E-mail Address. If multiple innovators, number each to match Box 5.)      

INNOVATOR’S EMPLOYER WHEN INNOVATION WAS MADE (For each innovator provide: Name, Division and Address of Employer, Organizational Code/Mail Code, and Contract/Grant Number if applicable. If multiple innovators, number each to match Box 5.)      

PLACE OF PERFORMANCE (Address(es) where innovation made)      

EMPLOYER STATUS (choose one for each innovator)             Innovator #1 Innovator #3             Innovator #2 Innovator #4 GE = Government CU = College or University NP = Non-Profit Organization SB = Small Business Firm LE = Large Entity

ORIGIN (Check all that apply and provide all applicable numbers. If multiple Contracts/Grants, etc., list Contract/Grant Numbers in Box 3 with applicable employer information.)

NASA In-house Org. Mail Code       Grant/Cooperative Agreement No.       Prime Contract No.       Task No.       Report No.       Subcontractor; Subcontract Tier       Joint Effort (contractor, subcontractor and/or grantee contribution(s), and NASA in-house contribution) Multiple Effort (multiple contractor, subcontractor and/or grantee contributions, no NASA in-house contribution) Other (e.g., Space Act Agreement, MOA) No.      

WBS       WBS       WBS       WBS       WBS      

NASA CONTRACTING OFFICER’S TECHNICAL REPRESENTATIVE (COTR)      

CONTRACTOR/GRANTEE NEW TECHNOLOGY REPRESENTATIVE (POC)      

BRIEF ABSTRACT (A general description of the innovation which describes its capabilities, but does not reveal details that would enable duplication or imitation of the innovation.)      

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SECTION I – DESCRIPTION OF THE PROBLEM OR OBJECTIVE THAT MOTIVATED THE INNOVATION’S DEVELOPMENT (Enter as appropriate: A. – General description of problem/objective; B. – Key or unique problem characteristics; C. – Prior art, i.e., prior techniques, methods, materials, or devices performing function of the innovation, or previous means for performing function of software; and D. – Disadvantages or limitation of prior art.)      

SECTION II – TECHNICALLY COMPLETE AND EASILY UNDERSTANDABLE DESCRIPTION OF INNOVATION DEVELOPED TO SOLVE THE PROBLEM OR MEET THE OBJECTIVE (Enter as appropriate; existing reports, if available, may form a part of the disclosure, and reference thereto can be made to complete this description: A. – Purpose and description of innovation/software; B. – Identification of component parts or steps, and explanation of mode of operation of innovation/software preferably referring to drawings, sketches, photographs, graphs, flow charts, and/or parts or ingredient lists illustrating the components; C. – Functional operation; D. – Alternate embodiments of the innovation/software; E. – Supportive theory; F. – Engineering specifications; G. – Peripheral equipment; and H. – Maintenance, reliability, safety factors.)      

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SECTION III – UNIQUE OR NOVEL FEATURES OF THE INNOVATION AND THE RESULTS OR BENEFITS OF ITS APPLICATION (Enter as appropriate: A. – Novel or unique features; B. – Advantages of innovation/software; C. – Development or new conceptual problems; D. – Test data and source of error; E. – Analysis of capabilities; and F. – For software, any re-use or re-engineering of existing code, use of shareware, or use of code owned by a non-federal entity.)      

SECTION IV – SPECULATION REGARDING POTENTIAL COMMERCIAL APPLICATIONS AND POINTS OF CONTACT (Including names of companies producing or using similar products.)      

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ADDITIONAL DOCUMENTATION (Include copies or list below any pertinent documentation which aids in the understanding or application of the innovation (e.g., articles, contractor reports, engineering specs, assembly/manufacturing drawings, parts or ingredients list, operating manuals, test data, assembly/manufacturing procedures, etc.).) TITLE PAGE DATE                                    

DEGREE OF TECHNOLOGY SIGNIFICANCE (Which best expresses the degree of technological significance of this innovation?) Modification to Existing Technology Substantial Advancement in the Art Major Breakthrough

STATE OF DEVELOPMENT Concept Only Design Prototype Modification Production Model Used in Current Work

PATENT STATUS (Prior patent on/or related to this innovation.) Application Filed Application No.       Application Date       Patent Issued Patent No.       Issue Date      

INDICATE THE DATE OR THE APPROXIMATE TIME PERIOD WHICH THIS INNOVATION WAS DEVELOPED (i.e., conceived, constructed, tested, etc.)      

PREVIOUS OR CONTEMPLATED PUBLICATION OR PUBLIC DISCLOSURE INCLUDING DATES (Provide as applicable: A. – Type of publication or disclosure, e.g., report, conference or seminar, oral presentation; B. – Disclosure by NASA or Contractor/Grantee; and C. – Title, volume no., page no., and date of publication.)      

QUESTIONS FOR SOFTWARE ONLY

(a) Using non-NASA employees to beta-test the program? YES NO If Yes, done under a beta-test agreement? YES NO (b) Modification of this program continued by civil servant and/or contractual agreement? YES NO (c) Copyright registered? YES NO UNKNOWN If Yes, then by whom?       (d) Has the latest version been distributed outside of NASA or contractor? YES NO UNKNOWN If Yes, date of first disclosure:       (e) Were prior versions distributed outside of NASA or Contractor? YES NO If Yes, supply NASA or contractor contract:       (f) Contains or based on code not owned by U.S. Government or its contractors? YES NO UNKNOWN If Yes, name of code and code’s owner:       Has a license for use been obtained? YES NO UNKNOWN

DEVELOPMENT HISTORY

STAGE OF DEVELOPMENT

DATE (MM/YYYY)

LOCATION

IDENTIFY SUPPORTING WITNESSES (NASA in-house only)

First disclosure to others

     

     

     

First sketch, drawing, logic chart or code

     

     

     

First written description

     

     

     

Completion of first model of full size device (invention) or beta version (software)

     

     

     

First successful operational test (invention) or alpha version (software)

     

     

     

Contribution of innovators (if jointly developed, provide the contribution of each innovator)      

Indicate any past, present, or contemplated government use of the innovation      

SIGNATURES OF INNOVATOR(S), WITNESS(ES), AND NASA APPROVAL

TYPED NAME AND SIGNATURE (Innovator #1)      

DATE      

TYPED NAME AND SIGNATURE (Innovator #2)      

DATE      

TYPED NAME AND SIGNATURE (Innovator #3)      

DATE      

TYPED NAME AND SIGNATURE (Innovator #4)      

DATE      

TYPED NAME AND SIGNATURE (Witness #1)      

DATE      

TYPED NAME AND SIGNATURE (Witness #2)      

DATE      

NASA APPROVED

TYPED NAME      

SIGNATURE

DATE      

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