NIST Inventor Information Form track changes

OMB Control Number: 0693-0085

Expiration Date: 01/31/2026

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 on the TPO 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 [email protected].

PRIVACY ACT STATEMENT

Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why the U.S. Department of Commerce (the Department), National Institute of Standards and Technology (NIST) is requesting the information on this form.

AUTHORITY:

The Department is authorized to collect the information on this form pursuant to 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:

This 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. NIST will use this information to track workflow, standardize processing, and provide data control in support of the Technology Transfer program.  

ROUTINE USES:

The information solicited on this form may be made available as a “routine use” pursuant to 5 U.S.C. § 552a(a)(7) and (b)(3). The information may be made available to other federal agencies to assist the Department in connection with NIST’s management of the purposes stated above; or for other authorized routine uses.

A complete list of the routine uses can be found in the system of records notice associated with this form, “COMMERCE/DEPT-23: Information Collected Electronically in Connection with Department of Commerce Activities, Events, and Programs.  This system of records notice can be found on the Department's website at https://www.commerce.gov/opog/system-records-notices-sorns

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION:

Providing this information is voluntary. However, failure to provide the requested information may result in an inability for NIST to process, review, and/or act on such requests. In limited circumstances, NIST may authorize the submission of the requested information via paper forms pursuant to the requirements in 15 CFR 748.1(d).