Early Stage Innovation Disclosure Form
1. Innovator Information
Name
Email
Department/Organization
2. Innovation Details
Title of Innovation
Description of Innovation
Problem Addressed / Unmet Need
Proposed Solution / Novelty
3. Development Stage
Current Stage of Development
Date of Conception
4. Collaborators
List Collaborators (Name, Department)
5. Prior Disclosure or Publication
Has this innovation been disclosed or published previously?
If yes, provide details
6. Additional Information
Additional Notes