Confidential Copyright Disclosure Form

(Click her to download this form as a .DOC file or as a .PDF file.)

Background
In compliance with WKU’s intellectual property policy and the requirements of the federal sponsoring agencies, the University students, staff and faculty are required to submit copyright disclosures to the Office of Technology Transfer. A completed copyright disclosure form below serves as the basis for an assessment and the decision for the intellectual property protection and commercialization potential. To complete the form, follow the guidelines below and DO NOT MODIFY THE FORM.

General Guidelines
Completion of a copyright disclosure form is the first step in a possible commercialization of a new knowledge base, new works such as literary works, performing arts, sound recording, visual arts, computer software, multimedia or thesis.
Give a concise title it will serve to identify the work.
Provide a brief description of the work, type of work such as literary works, performing arts, sound recording, visual arts, computer software, and multimedia. Identify if this work is based on any previous work already published or registered for copyright protection.
Identify features of this work that you consider are new and potential uses of this work.
If this work incorporates any other copyright protected works, attach copies of permission letters.
Describe similar works in the market. Outline the advantages of this new work, and how it is different than the existing work.
Identify all sources of funding such as grants, contracts that may have contributed to this new work.
Provide an exact date and forum of the first disclosure of this work. The disclosure and publication includes distribution of copies or recordings of a work to the public through journal publication, abstracts or other tangible forms for sale or other transfer of ownership, by rental, or lease, or lending. The work is also considered published or disclosed if it has been offered for public performance, or public display or offered for sale.
Provide names of individuals, organizations and dates that may have received copies of this work, and identify if these copies bear the copyright notice and the exact wording.
Identify the names of all contributors, and include the additional information on the form.
If you need additional information or need assistance in completing the form please contact the Office of Technology Transfer. Return the completed form and support documentation to the Office of Technology Transfer.

Sadiq Shah, Ph.D.
Office of Technology Transfer
Western Kentucky University
1906 College Height Blvd. - 11026
Bowling Green, KY 42101
Phone: (270) 745-2712
Fax: (270) 745-4211
sadiq.shah@wku.edu

For Office Use Only CD#:___________
Date Received:___________

Western Kentucky University
Confidential Copyright Disclosure Form

1. TITLE OF THE WORK:

 

2. DESCRIPTION OF THE WORK (Give a brief description of the work):

 

 

3. Date of first creation: __________________________________________________

4. Date of first working copy: ______________________________________________

Publication (month, day and year, medium and country): _________________________

_______________________________________________________________________

5. Type of work:

Literary Work: ___ Performing Arts: ___ Sound Recording: ___
Visual Arts: ___ Computer Software: ___ Multimedia: ___
Other: ___________

6. Contributing authors:

Names Department Affiliation Title

_________________________ _____________________ _________________

_________________________ _____________________ _________________

_________________________ _____________________ _________________

_________________________ _____________________ _________________

7. Is this work based on an earlier work that is already published?
Yes ____ No _____

If yes, identify the previous work by title

Has copyright registration been filed for the previous work?
Yes ____ No ____

8. Identify uses of this work:

 

 

9. Provide complete and accurate sources of financial support for this work:

Sponsor Grant Number/Contract
1.

2.

3.

4.

10. Did this work incorporate other works that is copyright protected:

Yes: ___ No: ___

If yes, describe specifics, and provide copies of permission letter

 

 

11. Identify distinguishing features of this work over existing works:

 

 

12. Identify potential users by names, address, e-mail address and phone numbers if available:

13. Has this work been publicly disclosed, If so please identify individuals, institutions/organizations and dates below:

Name Organization Date
_____________________ ___________________________ __________________
_____________________ ___________________________ __________________
_____________________ ___________________________ __________________
_____________________ ___________________________ __________________

14. If copies have been distributed, identify below:

Name Organization Date/Number of
copies
_____________________ ___________________________ __________________
_____________________ ___________________________ __________________
_____________________ ___________________________ __________________
_____________________ ___________________________ __________________

15. Did the above copies bear a copyright notice? Yes: ___ No: ___

Please identify below the exact wording of the copyright notice on distributed copies.

 

16. Is any disclosure planned/scheduled within the next six months?

Name Organization, place Date
_____________________ ___________________________ __________________
_____________________ ___________________________ __________________
_____________________ ___________________________ __________________
_____________________ ___________________________ __________________

17. Please identify the type of disclosure such as journal publication, abstract, distribution of copies, offer for sale, public display or public performance:

 

18. This disclosure is submitted in compliance with the Western Kentucky University intellectual property policy and is subject to all terms of the policy. I hereby agree to assist the Office of Technology Transfer in the legal protection and the commercialization process. Western Kentucky University will share any royalty income from this creation when commercialized with the inventors as outlined in the intellectual property policy.

Inventor(s) Signature Date Witnessed By
1.
2.
3.
4.
5.

19. Creators/Authors:
1. Name:
SS#:
Department:
Institution:
Phone #:
Fax #:
e-mail:
Home Address:

Citizenship

2. Name:
SS#:
Department:
Institution:
Phone #:
Fax #:
e-mail:
Home Address:

Citizenship
3. Name:
SS#:
Department:
Phone #:
Fax #:
e-mail:
Home Address:

Citizenship

4. Name:
SS#:
Department:
Phone #:
Fax #:
e-mail:
Home Address:

Citizenship

External collaborator(s):
1. Name:
SS#:
Department:
Phone #:
Fax #:
e-mail:
Home Address:

Citizenship

2. Name:
SS#:
Department:
Phone #:
Fax #:
e-mail:
Home Address:

Citizenship :