DOE F-200.4 Record of Invention

OMB Control No. 1910-0800 Exp. Date:  XX/XX/XXXX

DOE Form GC-213 (2-78) DOE PR-9-9 U.S. Department of Energy Office of Assistant General Counsel for Patents Record of Invention This Record of Invention is an important legal document and proper care in its early and complete preparation will save important time and inconvenience in the future. The Instructions on the back should be read carefully before filling in the data.				DOE Case No.:
A. Inventor Name(s) Employed by: 			Title or Position: Permanent Address: 
B. Title of Invention: 
C. Description of Invention: 
D. Dates and Places of Inventions: 1. Conception by Inventor at 2. First Sketch or Drawing at In Workbook ___________Page 3. First Written Description at In Workbook ___________Page 4. Disclosure to Others _____________________________ at_________________________________________ a. ______________________________________ 20 ____ at_________________________________________ b. ______________________________________ 20 ____ at_________________________________________ 5. Completion of Model or Full Size Device at 6. First Test or Operation of Invention ________________________________ at __________________________ 
E. Results of Tests and Extent of use of Invention: 		F. Names of all Persons having Knowledge of Facts Stated Under D and E: 
G. Pertinent Reports: 		H. Other Closely Related Publications, Patents, and Patent Applications: 
I. Rights of U.S. Government: 		J. Licenses or Assignments: 
K. Contracts Involved: Contractor and Address 		Contract Nos. 			Date: 
Type of Contract: Unclassified Restricted Confidential Secret
L. Signature of Witness:	Date:	Signature of Inventor (s):			Date:
Forwarded by:	Date:

Rev. 01/25/01

Public reporting burden for this collection of information is estimated to average 7.7 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information Officer, Records Management Division, IM-23, Paperwork Reduction Project OMB control number 1910-0800, U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project OMB control number 1910-0800, Washington, DC  20503.

INSTRUCTIONS

B. The title of the invention should indicate briefly the name of the article, device or type of machine, materials, composition, method, or process.

C. The description of the invention may be brief, provided reference is made to detailed specifications and drawings, which should be identified by origin, file numbers, and dates. Copies should be attached to this Report. At the end of the description there should be included a brief statement of what is claimed as new and patentable.

D.1. Give the earliest date on which, and the place where, the invention suggested itself, even though it was not completely in mind. If the invention comprises several different inventive ideas, give the conception dates of each part of the invention separately, taking care to identify each part clearly in the description of the invention.

D.4. Disclosure to others should be by written description or by sketches and should be authenticated in writing by two competent persons as follows: —Disclosed to and understood by me this _________ 20 ___ . (s) ____________________.“ Authentication of disclosure in workbooks is preferred.

E. State whether or not the invention was found to be operative, and the degree of success attained at each test of the model or full-sized device. In stating the extent of use of the invention, separate —use by the Government“ from —commercial use.“

G. List prior reports having a bearing on the problem to which the invention refers, giving origin, file numbers, and dates.

H. List all patents by number, date of grant, and title; list all applications for patents by filing dates, serial number, and title.

In forwarding the Record, an opinion should be given as to whether or not an application for a patent should be filed.

If the information submitted on this Record of Invention warrants a classification, the form should be appropriately classified.