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University Copyright Committee Disclosure Form
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NCSU Disclosure Form for Copyright Ownership Determination University Copyright Committee All sections must be completed |
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1. Current Date: 2. Date Submitted to Special Assistant to the Provost: |
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3. Title of the Work:
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4. Type of Work: (e.g., text, software, cd, film, etc.) |
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5. Creator(s) of the Work: Use additional pages if necessary |
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Name |
NCSU Status and description of contribution to work (“ideas” vs. actual tangible contribution) |
Contact Information |
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a. |
— Faculty/EPA — SPA — Student —Employed by NCSU — Non-NCSU —Other (please explain) Contribution:
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Address: ____________________ ____________________ Phone:______________ E-mail:______________ |
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b. |
— Faculty/EPA — SPA — Student —Employed by NCSU — Non-NCSU — Other (please explain) Contribution:
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Address: ____________________ ____________________ Phone:______________ E-mail:______________ |
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c. |
— Faculty/EPA — SPA — Student — Employed by NCSU — Non-NCSU — Other (please explain) Contribution:
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Address: ____________________ ____________________ Phone:______________ E-mail:______________ |
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6. Are the creators listed above aware that this disclosure is being made? |
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7. Is the appropriate supervisor aware that this disclosure is being made? Contact information:
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8. Creation of the Work |
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a. Please describe the inspiration for the work. That is, were you directed or instructed to do it? Was is part of your job description? Was it initiated by the creators?
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b. When was the work created? Is the work complete? Will the work be commercialized? |
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c. What funds and/or resources were used to create the work? This includes departmental funding, computer resources, students etc. If funds were used, indicate source, amount, and what they were used for:
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d. Was this work funded by a Sponsored Research Agreement? |
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Contract #: _____________ Sponsor: ______________ |
Effective Dates: From:______________ To: _______________ |
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e. Did the Sponsored Research Agreement contain an intellectual property clause that addressed copyright ownership? If so, please attach. |
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9. Disclosure Background a. Why are you submitting this disclosure?
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b. What is your question for the Copyright Committee?
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c. Do you have any pre-formed expectations concerning the answer to (b)?
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d. Have you read NCSU REG 01.25.03? |
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e. Notice: Even though you may be determined to be the copyright holder, NCSU may retain a “shop “right”, as defined in the above reg. You may need to disclose this to entities that may be the transferee of your copyright. |
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