MedStar Inventor Services Old Invention Disclosure Form Invention Disclosure Form Title of InventionDate of Invention (conception)Section BreakInvention Details1. Describe the invention in as much detail as possible. Feel free to attach any document file (.jpeg, .pdf, etc.) you feel helps to describe your invention. Please include who is the intended purchaser and user of the invention (may be different people or organizations).2. If applicable, illustrate your invention. A rough sketch is acceptable. Again, feel free to attach a document or photo if necessary.3. What problem does the invention solve?4. What are the advantages of the invention over other known technologies or solutions (please list)?5. Describe the current state of development for the invention (idea phase, prototype, and proof of concept studies started/complete).6. Has there been or is there a plan for any public disclosure of the invention? (manuscript submission/publication/poster/presentation/discussion outside of MedStar Health)7. List any known patents, patent applications, products, publications or other information relevant to the Invention.The following questions apply to Healthcare Information Technology (HIT) Inventions (e.g. software, websites, mobile apps) only and are optional.8. Please list any open-source elements included/embedded in the source code?9. Describe the language or operating system used to develop any applications and platforms on which the software will run. Is it easily portable to other platforms?10. What are the system requirements for the software? Does it require other products/software to run?As part of the Commercialization process your invention will be reviewed by a group of peer providers (Peer Review Committee). Please select one or two Peer Review Committees that are most relevant to provide clinical and technical feedback on your invention. Research Area (Circle all that apply) Anesthesia Cancer Medicine Dermatology & Plastics Digestive Disease Endocrinology Head and Neck Heart & Vascular Imaging Healthcare IT Medicine Neurological Nursing OBGYN/Women's Health Ophthalmology Orthopaedics Pathology/Lab Respiratory Urology Wellness Other Invention Domain Medical Device Therapeutic Diagnostic Healthcare Information Technology ("HIT") Business Solution Biological Tool (antibody, DNA, protein, etc.) Other MedStar Health is required to report government funded inventions to relevant funding agencies and provide a confidential copy of the disclosure. If an invention is made using industry or foundation funds, we are obligated to report such inventions to the sponsor, in accordance with the associated research grant/contract. Please identify any financial sponsors of the invention, as well as the relevant grant/contract numbers. Include institutional or department funding. Funding Source (Federal Agency, Society, Organization, etc.) Funding Source Grant, Contract Number, or Institutional/Departmental Initiative Funding Source Grant, Contract Number, or Institutional/Departmental Initiative Funding Source Grant, Contract Number, or Institutional/Departmental Initiative
