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INVENTION DISCLOSURE

This document is an essential preliminary to any procedure related to the exploitation of research results.

The purpose of this document is to collect the information required to understand the results of scientific research and to evaluate these results for protection and commercial potential. To this end, it contains a technical section and a section concerned with the economic opportunities afforded by the results. These aspects in combination will enable a decision to be made as to the best method of exploitation.

Any university is faced with choices when it intends to disseminate and exploit the results of its scientific research. Should they publish the results, keep them secret, protecting them by means of a patent, a registered design, or a brand or exploit them by means of a collaborative research with industry, signing a license with industry, creating a spin-off?

It is important to realize that the entire exploitation process can prove costly. In order to maximise the return on the effort, time and money expended by TTO officers and researchers, it is appropriate to clarify a few points: 1. Usable results are a set of new results that can be exploited industrially or commercially. It is therefore

inadvisable to begin a complete process of exploitation when the commercial potential is limited (for example, some research is too far upstream of any finished product; more advantageous alternatives are already on the market; the market is too restricted or immature, etc).

2. An invention does not necessarily form the subject of a patent application. It is important to bear in mind that other methods of exploitation can be taken up, depending on the context. The non-technical section of the invention disclosure therefore proves its worth here, since it makes it possible to specify the general context and evaluate the opportunity to select one method of exploitation over another.

3. The exploitation procedure is a long-term partnership between researchers and the technology transfer office. As such, both parties need to assess the importance of investing time and effort in the process.

4. Any researcher wishing to give an industrial dimension to his research will need to show prudence in reporting his results and in making use of the tools provided MTA, confidentiality agreements, etc.

The role of technology-transfer advisers is to support the researcher in the exploitation process. Thus, we remain at your service for any assistance you think it might be useful to obtain.

INVENTION DISCLOSURE = INVENTION ANNOUNCEMENT + INVENTION DESCRIPTION

DISTRIBUTION: Please submit the completed disclosure form by e-mail with password or via postal mail to your TTO.

Confidential 1

Invention announcement

FOR TECHNOLOGY TRANSFER OFFICE USE ONLY

TTO recommendations :

Co-ownership :AL-FUCAM AWB-ULB ADISIF – HE : to fill in AL-FUNDP AWB-UMONS Other : AL-Saint-Louis AWE-ULg Other : AL-UCL AWE-ULg GxABT Other : Methods of exploitation contemplated :Publication Patent License SoftwareResearch project Spin-off Biological material Other :

File number: TTO contact:

Confidential 2

GENERAL INFORMATION

Date :

Title of invention:

Contact name: Lab / Unit:

E-mail: Tel:

Short Description:

Technical originality and benefits:

Keywords:

Type of invention:

new compound, molecule new production process

new biotechnology new product

new use for a know product / process new device

other :

Is this invention related to any inventions you have previously disclosed? Yes No

If yes, which one?

Disclosure (written or oral)? No Yes

If yes:

Type of disclosure Medium Date of

disclosure Reference NDA 1

to fill in to fill in Yes No



1 Non-Disclosure Agreement. If yes, please supply a copy of the non-disclosure agreement.

Research funding:

Type Name / acronym Duration Industrial sponsor partner

to fill in

to fill in

Confidential 3

Contractual background:

Does the invention incorporate any material supplied by a third party? Yes No Does the invention incorporate any confidential results supplied by a third party? Yes No

If yes, please supply a copy of the MTA (material transfer agreement) or CDA (confidential disclosure agreement)

Laboratory notebooks:

Have filled any laboratory notebooks in which your invention is described? Yes No If so, are those notebooks available on request? Yes No

Confidential 4

MARKET POTENTIALWhat are the potential market segments for this technology?

Please, describe in a few words what is the potential of this technology with regard to its market potential:

Potential customers / users (please mention if you already have contacts with these users):

Potential competitors (public, private):

What are the advantages / disadvantages of your solution compared to competitors? What is the value proposition of your technology?

What is the development stage? to fill in

List the scientific and the application sectors that you think that might benefit from your technology. Be adventurous! Try to think of both broad and narrow applications, as well as applications that are outside of your own field (see definitions in Appendix).

Scientific sectors

Application sectors

1. Natural sciences

1.1 Mathematics (includes research on statistical methodologies but excludes applied statistics which should be classified under the relevant field of application)

1.2 Computer and information sciences (hardware development to be 2.2, social aspect to be 5.8)

1.3 Physical sciences

1.4 Chemical sciences

1.5 Earth and related environmental sciences (includes oceanography, hydrology)

1.6 Biological sciences (medical to be 3, agricultural to be 4)

1.7 Other natural sciences

2. Engineering and technology

2.1 Civil engineering

2.2 Electrical, electronic and information engineering

2.3 Mechanical engineering (includes nuclear engineering but nuclear physics to be 1.3)

2.4 Chemical engineering

2.5 Materials engineering (nanoscale materials to be 2.10, biomaterials to be 2.9)

2.6 Medical engineering (biomaterials to be 2.9)

2.7 Environmental engineering

2.8 Environmental biotechnology

2.9 Industrial biotechnology

Confidential 5

2.10 Nanotechnology (nanomaterials and nano-processes, biomaterials to be 2.9)

2.11 Other engineering and technologies

3. Medical and health sciences

3.1 Basic medicine (plant science to be 1.6)

3.2 Clinical medicine

3.3 Health sciences (includes services, sport, social biomedical sciences, ethics)

3.4 Medical biotechnology

3.5 Other medical sciences

4. Agricultural sciences

4.1 Agriculture, forestry and fisheries (agricultural biotechnology to be 4.4)

4.2 Animal and dairy sciences (animal biotechnology to be 4.4)

4.3 Veterinary sciences

4.4 Agricultural biotechnology

4.5 Other agricultural sciences

5. Social sciences 5.1 Psychology (includes therapy for learning, speech, hearing and other disabilities)

5.2 Economics and business

5.3 Educational sciences (includes training, pedagogy, didactics)

5.4 Sociology

5.5 Law

5.6 Political sciences

5.7 Social and economic geography (transport engineering to be 2.1)

5.8 Media and communications

5.9 Other social sciences

6. Humanities 6.1 History and archeology (history of science and technology to be 6.3)

6.2 Languages and literature

6.3 Philosophy, ethics and religion

6.4 Arts, history of arts, performing arts, music

6.5 Other humanities

7. Other To describe

Confidential 6

Confidential 7

CONTRIBUTORSPlease list all contributors to the invention known at this time. The list of inventors will be finalized later, after consultation with your Technology Transfer Office.

Last Name Description of contribution to the inventionFirst Name Institution Research unit Phone Email Funding to fill in if other, precise: Last Name Description of contribution to the inventionFirst Name Institution Research unit Phone Email Funding to fill in if other, precise: Last Name Description of contribution to the inventionFirst Name Institution Research unit Phone Email Funding to fill in if other, precise: Last Name Description of contribution to the inventionFirst Name Institution Research unit Phone Email Funding to fill in if other, precise: Last Name Description of contribution to the inventionFirst Name Institution Research unit Phone Email Funding to fill in if other, precise: Last Name Description of contribution to the inventionFirst Name Institution Research unit Phone Email Funding to fill in if other, precise: Last Name Description of contribution to the inventionFirst Name Institution Research unit Phone Email Funding to fill in if other, precise: Last Name Description of contribution to the inventionFirst Name Institution Research unit Phone Email Funding to fill in if other, precise:

Confidential 8

Invention description

Confidential 9

DESCRIPTION

Provide a description of the technical field of this invention. Please, supply additional documents if appropriate.

- For new product / compound / biotechnology, give the formula, diagram, physic-chemical characteristics or, failing this, preparation procedure and properties;

- For new device, give the essential items backed by figures;- For new process, give the essential and original stages;- For new use for a know product / process, give the new potential applications, the new stages.

Confidential 10

PRIOR ART

Notice: this page is to be completed following the procedures put in place by the various universities. Please, contact your TTO for further information.

Are there other research or industrial teams who work in the field of the invention? Yes No

If yes, please, list and attach copies of any publications (scientific or commercial publications) and/or patents, oral or written, that discloses ideas most closely related to the invention:

What were the keywords used to perform the search?

Has a search been carried out based in databases of patents? Yes No

If yes, complete the following table:

IDKeywords or classification

codeSearch tool Search field Number of

documents

Number of relevant

documents

1 to fill in to fill in





Please, list and attach the most relevant documents found among patents identified:1. 2. 3.

Was a first search carried out by PICARRE in collaboration with the researchers? Yes No

If so, please, enclose the search strategy used in appendix, together with an analysis of previous work that is relevant in terms of its difference in relation to this invention and the conclusion drawn.

Search date:

What are the novel aspects of your invention? How does it improve upon prior art? What issue does your invention address?

Confidential 11

MARKET POTENTIAL

What is the global market size? to fill in

Specify if appropriate:

What is the geographic market size? to fill in


What is the market structure? to fill in


What is the market evolution trend?

The market: to fill in


If you hold publication references about market datas, please mention them here:

Are there regulatory constraints relating to the product commercialization?

Yes No

If yes, please specify:

Is there a risk in the industrialization process: to fill in

Are there other entry barriers?

Please mention here additional information that could be important:

Confidential 12

POTENTIAL PRODUCTS

Which products and services might be offered using the technology?

Product or Services Please detail the development stage

Time needed to reach ready to

license-out

Do you have resources people, funds to develop the technology to reach the ready to license-out stage?

Do you have sample or prototypes that can be provided to potential licensee for technology's

evaluation?

to fill in Yes No Yes No




If no prototype or sample are available, would you be willing to produce these in order assist in-licensing efforts? Yes No

What is the life cycle duration of the product?

expected life cycle: to fill in

Could several products be derived from the technology?

Please mention competitor products/processes:

If there is no direct competitor, what are the current existing solutions?

The product or process:

YES NO ?

is CHEAPER to make or use than currently available products or processes

is less complicated, less labor intensive, more user friendly than currently available products or process (EASIER TO USE)

is less complicated to make, or its manufacturing process is less complex than those of currently available products (EASIER TO MAKE)

is SAFER for the operator, bystanders or animals than currently available products or process

works FASTER than currently available product or processes

yields MORE ACCURATE results than those usually achieved using currently available product or processes

is more compact, or is larger and with greater capacity than currently available products (BETTER SIZE)

Confidential 13

is lighter or heavier whichever is preferable than currently available products (BETTER WEIGHT)

is less complicated or costly to fix or adjust than currently available products (EASIER TO FIX)

breaks down less frequently, or the process is more consistently successful than with currently available products or processes (MORE RELIABLE)

recycles materials that normally end up in landfill sites or is less polluting than currently available products or processes (MORE ECOLOGICAL)

is MORE DURABLE than currently available products

is sufficiently similar to currently available products or processes that users or manufacturers will easily be able to switch (EASY TO SWITCH)

Competitors will have difficulty producing an equivalent product or process, or in solving problems without it (HARD TO DUPLICATE)

Is easier and cheaper to make than currently available products or processes but can be sold at a comparable price (HIGHER PROFIT MARGIN)

Is it possible to quantify the value proposition of the product? Yes No

o If yes, how?


Confidential 14

POTENTIAL LICENSEES

Who are the potential licensees?

List the names of companies you think might be interested in using your technology to make, use or sell products or services. If you have a contact at any of these companies, be sure to provide name, position, e-mail and telephone. (We will obtain your permission before contacting anyone).

CompanyHave you had contacts with this company?

Contact Name Position/Title E-mail Phone

Does this company

already offer a similar

product?

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

In case of previous contacts with companies, was there a CDA in place? Yes No

If yes, please supply a copy of the CDA (confidential disclosure agreement)

Would you be willing to speak to potential licensees about your technology Yes No

If / when we license the technology, would you be willing to collaborate with the licensing company as a principal or as a scientific advisor? Yes No

If a spin-off company is created, would you be willing to participate in? Yes No

o If yes, what could be your role?


Confidential 15

SIGNATURES

WARNING: inventorship is a matter of law and the below list should include the name of all persons who may qualify as legal inventor. An incomplete list of inventors, or a list that includes persons who have not in fact contributed to the inventive work, may therefore result in the lapse or invalidity of a patent.

Inventors (to be signed before witnesses) I have acquainted myself with the University's rules, which I accept. My signature at the foot of this document confirms my agreement to the Research Department's administrative procedure for an invention disclosure. I agree to co-operate fully with the TTO by supplying any document or information required for the registration, upkeep and possible defense of patents, negotiations of license contracts and the exploitation of the results of my research. I undertake to sign any document required for the registration or issue of patent applications, also an inventor's agreement, whose purpose is to settle the method of distributing income earned by exploiting the invention. I undertake not to disclose the invention either orally or in writing during the priority period of the patent application without notifying the TTO.

Inventor #1 Inventor #2Last name: First name: Last name: First name: Inventor's share (%): Nationality: Inventor's share (%): Nationality: Private e-mail: Private e-mail: Private phone no.: Private phone no.: Legal address: Legal address: Position: Position: Date & signature Date & signature



Witnesses. To be signed by two witnesses, including the head of department and an external witness (the last-named to be subject to a confidentiality agreement) who have understood the invention solely on the basis of this document.

On (date), I read this invention disclosure and understood its content. Last name, first name Signature

On (date), I read this invention disclosure and understood its content. Last name, first name Signature

Confidential 16

APPENDIX

Domain Subdomain Details

1. Natural sciences 1.1. Mathematics • Pure mathematics, Applied mathematics; Statistics and probability. This includes research on statistical methodologies, but excludes research on applied statistics which should be classified under the relevant field of application (e.g. Economics, Sociology, etc.)

1.2. Computer and information sciences

• Computer sciences, information science and bioinformatics (hardware development to be 2.2, social aspect to be 5.8)

1.3. Physical sciences • Atomic, molecular and chemical physics (physics of atoms and molecules including collision, interaction with radiation; magnetic resonances; Moessbauer effect); Condensed matter physics (including formerly solid state physics, superconductivity); Particles and fields physics; Nuclear physics; Fluids and plasma physics (including surface physics); Optics (including laser optics and quantum optics), Acoustics; Astronomy (including astrophysics, space science)

1.4. Chemical sciences • Organic chemistry; Inorganic and nuclear chemistry; Physical chemistry, Polymer science, Electrochemistry (dry cells, batteries, fuel cells, corrosion metals, electrolysis); Colloid chemistry; Analytical chemistry

1.5. Earth and related environmental sciences

• Geosciences, multidisciplinary; Mineralogy; Palaeontology; Geochemistry and geophysics; Physical geography; Geology; Volcanology; Environmental sciences (social aspects to be 5.7);

• Meteorology and atmospheric sciences; climatic research;

• Oceanography, Hydrology, Water resources

1.6.Biological sciences (Medical to be 3, and Agricultural to be 4)

• Cell biology, Microbiology; Virology; Biochemistry and molecular biology; Biochemical research methods; Mycology; Biophysics;

• Genetics and heredity (medical genetics to be 3); reproductive biology (medical aspects to be 3);developmental biology;

• Plant sciences, botany;

• Zoology, Ornithology, Entomology, Behavioural sciences biology;

• Marine biology, freshwater biology, limnology; Ecology; Biodiversity conservation;

• Biology (theoretical, mathematical, thermal, cryobiology, biological rhythm), Evolutionary biology; other biological topics

1.7. Other natural sciences

2. Engineering and technology 2.1. Civil engineering • Civil engineering; Architecture engineering; Construction

Confidential 17

engineering, Municipal and structural engineering; Transport engineering

2.2. Electrical, Electronic and Information engineering

• Electrical and electronic engineering; Robotics and automatic control; Automation and control systems; Communication engineering and systems; telecommunications; Computer hardware and architecture

2.3. Mechanical engineering • Mechanical engineering; Applied mechanics; Thermodynamics;

• Aerospace engineering;

• Nuclear related engineering; (nuclear physics to be 1.3);

• Audio engineering, reliability analysis

2.4. Chemical engineering • Chemical engineering (plants, products); Chemical process engineering

2.5.Materials engineering • Materials engineering; Ceramics; Coating and films; Composites (including laminates, reinforced plastics, cermets, combined natural and synthetic fibre fabrics; filled composites); Paper and wood; textiles; including synthetic dyes, colours, fibres; (nanoscale materials to be 2.10; biomaterials to be 2.9);

2.6. Medical engineering • Medical engineering; Medical laboratory technology (including laboratory samples analysis; diagnostic technologies); (Biomaterials to be 2.9 [physical characteristics of living material as related to medical implants, devices, sensors])

2.7. Environmental engineering • Environmental and geological engineering, geotechnics; Petroleum engineering, (fuel, oils), Energy and fuels; Remote sensing; Mining and mineral processing; Marine engineering, sea vessels; Ocean engineering

2.8. Environmental biotechnology • Environmental biotechnology; Bioremediation, diagnostic biotechnologies (DNA chips and biosensing devices) in environmental management; environmental biotechnology related ethics

2.9. Industrial biotechnology • Industrial biotechnology; Bioprocessing technologies (industrial processes relying on biological agents to drive the process) biocatalysis, fermentation; bioproducts (products that are manufactured using biological material as feedstock) biomaterials, bioplastics, biofuels, bioderived bulk and fine chemicals, bio-derived novel materials

2.10. Nano-technology • Nano-materials [production and properties];

• Nano-processes [applications on nano-scale]; (biomaterials to be 2.9)

2.11. Other engineering and technologies

• Food and beverages;

• Other engineering and technologies

Confidential 18

3. Medical and Health sciences

3.1. Basic medicine • Anatomy and morphology (plant science to be 1.6); Human genetics; Immunology; Neurosciences (including psychophysiology); Pharmacology and pharmacy; Medicinal chemistry; Toxicology; Physiology (including cytology); Pathology

3.2. Clinical medicine • Andrology; Obstetrics and gynaecology; Paediatrics; Cardiac and Cardiovascular systems; Peripheral vascular disease; Hematology; Respiratory systems; Critical care medicine and Emergency medicine; Anaesthesiology; Orthopaedics; Surgery; Radiology, nuclear medicine and medical imaging; Transplantation; Dentistry, oral surgery and medicine; Dermatology and venereal diseases; Allergy; Rheumatology; Endocrinology and metabolism (including diabetes, hormones); Gastroenterology and hepatology; Urology and nephrology; Oncology; Ophthalmology; Otorhinolaryngology; Psychiatry; Clinical neurology; Geriatrics and gerontology; General and internal medicine; other clinical medicine subjects; Integrative and complementary medicine (alternative practice systems)

3.3. Health sciences • Health care sciences and services (including hospital administration, health care financing); Health policy and services;

• Nursing; Nutrition, Dietetics;

• Public and environmental health; Tropical medicine; Parasitology; Infectious diseases; epidemiology;

• Occupational health; Sport and fitness sciences;

• Social biomedical sciences (includes family planning, sexual health, psycho-oncology, political and social effects of biomedical research); Medical ethics; Substance abuse

3.4. Medical biotechnology • Health-related biotechnology; Technologies involving the manipulation of cells, tissues, organs or the whole organism (assisted reproduction); Technologies involving identifying the functioning of DNA, proteins and enzymes and how they influence the onset of disease and maintenance of well-being (gene-based diagnostics and therapeutic interventions pharmacogenomics, gene-based therapeutics); Biomaterials (as related to medical implants, devices, sensors); Medical biotechnology related ethics

3.5. Other medical sciences • Forensic science

• Other medical sciences

Confidential 19

4. Agricultural sciences 4.1. Agriculture, Forestry, and Fisheries

• Agriculture; Forestry; Fishery; Soil science; Horticulture, viticulture; Agronomy, plant breeding and plant protection; (Agricultural biotechnology to be 4.4)

4.2. Animal and Dairy science • Animal and dairy science; (Animal biotechnology to be 4.4)

• Husbandry; Pets

4.3. Veterinary science

4.4. Agricultural biotechnology • Agricultural biotechnology and food biotechnology; GM technology (crops and livestock), livestock cloning, marker assisted selection, diagnostics (DNA chips and biosensing devices for the early/accurate detection of diseases) biomass feedstock production technologies, biopharming; agricultural biotechnology related ethics

4.5. Other agricultural sciences

5. Social sciences 5.1. Psychology • Psychology (including human - machine relations); • Psychology, special (including therapy for learning, speech, hearing, visual and other physical and mental disabilities)

5.2. Economics and business • Economics, Econometrics; Industrial relations;

• Business and Management

5.3. Educational sciences • Education, general; including training, pedagogy, didactics;

• Education, special (to gifted persons, those with learning disabilities)

5.4. Sociology • Sociology; Demography; Anthropology, ethnology,

• Social topics (Women’s and gender studies; Social issues; Family studies, Social work)

5.5. Law • Law, criminology, penology

5.6. Political science • Political science; public administration; organisation theory

5.7. Social and economic geography

• Environmental sciences (social aspects); Cultural and economic geography; Urban studies (Planning and development); Transport planning and social aspects of transport (transport engineering to be 2.1)

5.8. Media and communications • Journalism; Information science (social aspects); Library science; Media and socio-cultural communication

5.9. Other social sciences • Social sciences, interdisciplinary;

• Other social sciences

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6. Humanities 6.1. History and Archaeology • History (history of science and technology to be 6.3, history of specific sciences to be under the respective headings); Archaeology

6.2. Languages and Literature • General language studies; Specific languages; General literature studies; Literary theory; Specific literatures; Linguistics

6.3. Philosophy, Ethics and Religion

• Philosophy, History and philosophy of science and technology;

• Ethics (except ethics related to specific subfields); Theology; Religious studies

6.4. Arts (arts, history of arts, performing arts, music)

• Arts, Art history; Architectural design; Performing arts studies (Musicology, Theater science, Dramaturgy); Folklore studies;

• Studies on Film, Radio and Television

6.5. Other humanities

Confidential 21

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