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When completed submit to:

Office of Technology Transfer


1599 Clifton Rd., NE, 4th Floor

Atlanta, Georgia 30322


(404) 727-2211

Emory Mouse Model

Disclosure Statement Form


(for OTT internal use only)

File No. _____________

Publication Yes No

Government Yes No

OTT Reviewer ____________________





The purpose of this form is to facilitate the prompt disclosure by Emory Personnel of any research tool to which Emory may assert ownership rights pursuant to Section I of the Emory University Intellectual Property Policy (adopted June 6, 2002).

1. Title of Mouse Model


2. Type of Mouse Model


Genetically engineered targeted
mutation (sec. 6.1)

Targeted gene:

ES cell line:

Genetially engineered transgene


(sec. 6.1)

Transgene:

Promotor:

Founder line number:

Common name:


Non-targeted, induced mutation
(transgene insertion, gene trap,
chemical, radiation) (sec. 6.1)

Affected gene:

Method:

Spontaneous mutation (sec. 6.1)

Strain name:


Inbred (sec. 6.2)

Recombinant inbred


(sec. 6.2)

Recombinant congenic


(sec. 6.2)

Consomic (chromosome


substitution) (sec. 6.2)


3. Contributor(s)


Position

Department


% Contribution

_____%


_____%

_____%


_____%

VA

CHOA


Ga. Tech


Other Institution (name)

(Please list all persons who are believed to have made significant contributions to the mouse model including Emory Personnel as well as other Contributors at other institutions.)

4. Was this mouse model developed with the use of any research grant/contract funds? Yes No

Contract No(s) Sponsor(s) OSP UPN No(s) Principal Investigator

Note: this information is required pursuant to 37 CFR 401.14(f)(2)

5. Please list any Material Transfer Agreements (incoming and/or outgoing) or other agreements (other than those listed in 5 above) that are related to this mouse model.

Institution/Company OTT No(s) Date(s) Material




Section 6.1

a. Description of the mutation: recessive dominant semi-dominant

Molecular defect (if known):

b. Mutant phenotype: are homozygous mice viable? Yes No

Comment:

Are homozygous mice fertile? Yes No

Comment:

c. Strain genetic background:

On what genetic background did strain originate? (include substrain if known)

On what genetic background is it maintained? (include substrainif known)

Is it inbred? Yes No If yes, number of generations

d. Maintenance of the strain:

On what genetic background did strain originate? (e.g,. homozygous x homozygous)

How good is reproduction?

Are there any special husbandry requirements?

e. Mutant identification:

Do breeders require testing? Yes No

What type of testing? (check all that apply) PCR Southerns Phenotype Identification Other

Description of other:


Section 6.2

Strain name:

Strain characteristics:

Origin of strain:

Is it inbred? Yes No If yes, number of generations

For congenics, number of backcross generations:

What is your current breeding system?

How good is reproduction?

Are there any special husbandry requirements?


7. What type of research is this strain useful for?


8. Does this strain model a human condition?


9. If this is a genetically engineered strain, were any of the following technologies used at any point in its construction?

Cre-lox technology FLP recombinase technology Tet-system technology






10. Please list any publications or articles which describe the development or use of the mouse model.


11. Please attach a list of any commercial entities that may be interested in this mouse model (provide as much detail as possible)


I (we) hereby declare that all statements made herein of my own knowledge are true and that all statements made on information and belief are believed to be true.

Pursuant to the Emory University Intellectual Property Policy, I (We) hereby confirm the assignment of all of my (our) right, title and interest to this Intellectual Property to Emory University and agree to execute all documents as requested, to assign to Emory University all of my (our) rights to any patent application filed on this Intellectual Property, and to cooperate with the Emory University Office of Technology Transfer in the protection of this Intellectual Property. Emory University will share any royalty income derived from the Intellectual Property with the inventor(s) according to its standard policies. (Please attach any additional signatures.)

Contributor’s Signature (Emory Personnel) Date



Campus Address



Campus Phone Campus Email Address



Home Address City, State, Zip



Country of Citizenship



Contributor’s Signature (Emory Personnel) Date



Campus Address



Campus Phone Campus Email Address



Home Address City, State Zip



Country of Citizenship




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