Form Approved Through 10/312018OMB No. 0925 - PDF document

��HHS 568 (Rev. 06/15) Form Approved Through 03 /31 / 20 20 OMB No. 0925 Department of Health and Human ServicesFinal Invention Statement and Certification (For Grant or Award ) DHHS Grant or Award No. A. We hereby certify that, to the best of our knowledge and belief, all inventions are listed below which wereconceived and/or first actually reduced to practice during the course of work under the abovereferenced DHHSgrant or award for the period through . original effective date date of termination B. Inventions (Note: If no inventions have been made under the grant or award, insert the word “NONE” under NAME OF INVENTOR TITLE OF INVENTION DATE REPORTED TO DHHS (Use continuation sheet if necessary) C . Signature — This block must be signed by an official authorized to sign on behalf of the institution . Title Name and Mailing Address of Institution Typed Name Signature Date Form Approved Through 03/312020OMB No. 0925 Procedure for Submission ofFinal Invention Statement and Certification (For Grant or Award)Form HHS 568 Inventiontatement andertification(Form HS hall xecuted and submitted within 90 days ollowing the xpiration or ermination of ant warThe tatement hall include ll nventions hich were conceived or irst ctually reduced to practice ing ourse ork under the grant ward, from riginal ffective te upport hrough the te completion or ermination. The tatement hall nclude ny nventions eported previously grantardarta non-competing pplication. This eporting equirement ispplicablegrants nd awards epartment ealth and Human Services n support esearch. The inal Invention Statement nd Certification does n any way elieve rson responsible for he grant ward, or nstitution, of igation to assure hat ll nventions re omptly and fully reported directly to the ational Institutes ealth, as equired by terms he grant awarInformation regarding eporting nventions, including eporting orm followed, may ained from ffice olicy for xtramural esearch Administration, Division of xtramural Inventions nd Technology Resources, 6705 Rockledge rive SC Bethesda, Maryland 20892-7980, Telephone: 301) The iginal of ompleted Final Invention Statement nd Certification is eturned to the awarding omponent hat unded the grant ward. The ntire grant ward number ust ppear in the signated box on the orm. The riod covered by he Final Inventiontatement isproject riod of he grant warat rticular grantee nstitutiIf no inventions ere involved, insert ord None” n the first ock tem itle Invention. Each Statement requires ignature an institution official uthorized to sign on behalf of nstitution. Publiceportingurdenorisollectionnformationstimatedaryfrom5 to 10minutesperesponse,including thetimeforeviewing instructions,searchingxistingata sources,gatheriandaintaininghe data needed,ompleting andeviewing thcollectionformationAnncmanotonductponsor,person isequired toespond to,ollection ofnformation unlesssplaysurrentlyalid OMBcontrolnumber.Sendcommentsegardinghisrdenstimateherspecthisllectionnformation,ncludingsuggestionsforeducingthisurden to:IH,rojectlearanceBranch,RockledgDrive MSCethesda, DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved Through 03/312020OMB No. 0925 Procedure for Submission ofFinal Invention Statement and Certification (For Grant or Award)Form HHS 568 Inventiontatementertification(Forhalxecuted and submitted within 90 dayollowing txpiration or ermination of wartatemehall inclnventihich werconceived or irsctuallreduced to practicinourse ork undegraward, frriginaffectiupporhrough tcompletion or ermination. Ttatemehalnclnventieported previouslgrantardarta non-competinpplication. Thieportiequiremenlicablegrantnd awarepartmeealth and Human Servicen supporesearch. inaInvention Statemend Certification doen anwaelievrson responsible graward, or nstitution, of igation to assurhanventiomptly and fullreported directlto tationaInstituteealth, aequired btermgraawarInformation regardieportinnventions, includieportifollowed, maained frfficolicxtramuraesearch Administration, Division of xtramuraInventind TechnoloResources, 6705 RockleriBethesda, Maryland 20892-7980, Telephoneiginaompleted FinaInvention Statemend Certification ieturned to the awardinomponeunded tgraward. Tntirgraward numbeppear in tsignated box on torm. Triod covered bFinaInvention Statemenprojecriod of granwarrticulagrantenstitutino inventiere involved, inserNonefirsteitlInvention. Each Statement requireignaturan institution officiauthorized to sign on behalnstitution. Publiceportingurdenorisollectionnformationstimatedaryfromto 10minutesperesponse,including thetimeforeviewing instructions,searchingxistingata sources,gatheriandaintaininghe data needed,ompleting andeviewinthecollectionformationAnncmay notnductponsor,person isequired toespond to,ollection ofnformatiounlesssplaysurrentlyalid OMBcontrolnumber.Sendcommentsegardinghisrdenstimateherspecthisllectionnformation,ncluding DEPARTMENT OF HEALTH AND HUMAN SERVICES