DN-45 NIST Inventor Information Form

DN45

OMB Control Number: 0693-0085

Expiration Date: 11/30/2022

Inventor Information

(To be completed by each Inventor)

Instructions: Please insert your brief answers into the shaded fill boxes using Word. The boxes will expand as you enter information. Additional forms are in the Forms section of the OTP website. All fields must be completed.

1. Invention Title:

     

2. Your Full Legal Name:          

3. Work Address:

     

Phone/email/fax:     

Home Address:

     

Phone/email/fax:     

4. Citizenship: USA

Other      

5. Current Employer:

NIST

Other      

Address: (if different from work address listed above)

     

6. Referring to the dates of conception and reduction to practice given in Question 4 of the Invention Disclosure Sheet, who was your employer during the following:

1. Invention conception:

a. NIST

b. Other       Your relationship to NIST:      

Was your participation funded in any part by the Federal Government? yes no

2. Invention reduction to practice:

a. NIST

b. Other       Your relationship to NIST:     

Was your participation funded in any part by the Federal Government? yes no

7. Did your employer change during the time frame that you contributed to the conception and to the reduction to practice of the invention? If yes, please explain. yes no

     

8. Non-NIST employees only: Attach a copy of any agreement relevant to the disclosed invention under which you worked at NIST and/or collaborating with NIST staff.

9. NIST employees:

   1. Was the invention:

related to your official duties?

made during working hours?

made with the contribution of government facilities, equipment, materials, or funds?

made with information obtained from your employment at NIST?

made with time or services of other government employees on official duty?

2. Were you working under any type of agreement related to the invention with a party other than NIST when you contributed to the invention? (If yes, please briefly describe) yes no

     

10. Please describe your role in creating the invention.

     

11. Having read the invention disclosure information document, do you believe you are an inventor of the invention as described in the attached material? yes no

12. Are you aware of any disputes over inventorship of the invention? yes no

Name:       Signature______________________ Date__________

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0693-0085. Without this approval, we could not conduct this survey/information collection. Public reporting for this information collection is estimated to be approximately 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. All responses to this information collection are voluntary. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to the National Institute of Standards and Technology, 100 Bureau Drive, Gaithersburg, MD 20899, Attn: Jeffrey DiVietro, [email protected].

Privacy Act Statement:

Authority: The National Institute of Standards and Technology Act, as amended, 15 U.S.C. 271 et seq. (which includes Title 15 U.S.C. 272) and section 12 of the Stevenson-Wydler Technology; Innovation Act of 1980, as amended,35 U.S.C. §200; 35 U.S.C. §207

Purpose: Information is collected for the National Institute of Standards and Technology (NIST), Technology Partnerships Office (TPO) to streamline the NIST invention disclosure and review processes and to make them scalable to a larger number of disclosed inventions.

Routine Uses: NIST will use this information to track work flow, standardize processing, and provide data control in support of the Technology Transfer program. Disclosure of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 522a) to be shared among NIST staff for work-related purposes. Disclosure of this information is also subject to all the published routine uses as identified in the Privacy Act System of Records Notices: COMMERCE/DEPT-23: Information Collected Electronically in Connection with Department of Commerce Activities, Events, and Programs.

Disclosure: Furnishing this information is voluntary. When supplying the information, you are indicating your voluntary consent for NIST to use the information you submit for the purpose stated.