Technology Contributor Form | Center for Technology Transfer & Commercialization

Because you have been listed as an inventor on the Invention Disclosure entitled below, please complete this form. The Invention Disclosure is not complete until ALL contributors have filled out and submitted this Technology Contributor Form and digitally signed the Disclosure Certification Page. Once you have completed this Contributor form, please click Submit to be directed to the Disclosure Certification Page (login with your VUNet ID may be required).

Technology Details

Disclosure Title *

Personal Information

Contributor's Name.

Please provide the inventor’s first and last name - if the fields have been prepopulated for you please verify that it is correct.

First Name *

Middle Name

Last Name *

Suffix

Employer Information

Please indicate the entities by which you are employed or primarily appointed.

Employed by *

Primary School *

Other School

You've selected other as the primary school, please indicate the name of the primary school by which you are employed or assigned.

Other Primary School *

Departments of Blair School of Music *

Other Department

You've selected other as the department, please indicate the name of the department by which you are employed or primarily assigned.

Other Department *

Departments of Arts and Science *

Other Department

You've selected other as the department, please indicate the name of the department by which you are employed or primarily assigned.

Other Department *

Owen Graduate School of Management *

Other Department

You've selected other as the department, please indicate the name of the department by which you are employed or primarily assigned.

Other Department *

Departments of Peabody College *

Other Department

You've selected other as the department, please indicate the name of the department by which you are employed or primarily assigned.

Other Department *

Departments of School of Engineering *

Other Department

You've selected other as the department, please indicate the name of the department by which you are employed or primarily assigned.

Other Department *

Departments of School of Medicine *

Other Department

You've selected other as the department, please indicate the name of the department by which you are employed or primarily assigned.

Other Department *

Departments of School of Nursing *

Other Department

You've selected other as the department, please indicate the name of the department by which you are employed or primarily assigned.

Other Department *

Division of the Administrative Department *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Department *

Divisions of the Department of Anesthesiology *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Biomedical Informatics *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Biostatistics *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Cardiac Surgery *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Emergency Medicine *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Hearing and Speech Sciences *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Medicine *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Neurological Surgery *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Neurology *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Obstetrics and Gynecology *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Ophthalmology and Visual Sciences *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Oral and Maxillofacial Surgery *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Orthopaedic Surgery and Rehabilitation *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Otolaryngology *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Pathology, Microbiology and Immunology *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Pediatric Surgery *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Pediatrics *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Physical Medicine and Rehabilitation *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Plastic Surgery *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Psychiatry *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Radiation Oncology *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Radiology and Radiological Sciences *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Surgery *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Thoracic Surgery *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Division of the Department of Urologic Surgery *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Other Department

You've selected other as the primary department, please indicate the name of the primary department by which you are employed or assigned.

Other Department School *

Division of the Administrative Department *

Other Division Fieldset

You've selected other as the division, please indicate the name of the division by which you are employed or primarily assigned.

Other Division *

Centers and Institutes

Please list all centers and Institutes that provided support for development of this technology.

Centers *

Other Centers

You've selected Other, please indicate the name(s) of the center(s).

Other Center School *

Institutes *

Other Institutes

You've selected Other, please indicate the name of the institutes.

Other Institutes *

Please provide the name of the employer in which you are employed or assigned during this invention.

Employer Name *

Veterans Affairs (VA) *

Are you affiliated with Veterans Affairs (VA)?

Yes, I am dually appointed.

Yes, without compensation (WOC)

No, I have no VA appointment

Exclusively perform clinical, attending, or educational activities at VA.

VA Exclusivity

Contact Information

Primary E-Mail *

Alternative E-Mail

Primary Phone Number *

Alternative Phone Number *

Home Address

Please provide your current address by first selecting the country.

Home Address

Country

Address 1 *

Address 2

City *

State *

ZIP code *

Country of Citizenship

Country of Citizenship *

Disclosure Information

If you need to view the disclosure, click here

Contribution *

None
Bill Wilkerson Center
Biomedical Ethics and Society Center
Biophotonics Center
Center for Evaluation and Program Improvement
Center for Health Services Research
Center for Human Genetics Research
Center for Integrative Health
Center for Intelligent Mechanotronics
Center for Molecular Neuroscience
Center for Patient & Professional Advocacy
Center for Professional Health Advocacy
Center for Research in Practice
Center for Stem Cell Biology
Center for Structural Biology
Center for Teaching
Center in Molecular Toxicology
Center Neuroscience Drug Discovery
Diabetes Center
Digestive Disease Research Center
Center for Epithelial Biology
Kennedy Center
Mass Spectrometry Research Center
Transplant Center
Vaccine Center
Vanderbilt Ingram Cancer Center (VICC)
Other