Intellectual Property Notification and Compliance Form

Intellectual Property Notification and Compliance Form
Name*

First NameLast Name
Department*
Phone*

Area CodePhone Number
Email*
Title of Book or Other Intellectual Property*
Names of All Authors*
Publisher*
Year of Publication*
The course(s) in which this material will be assigned *
The semester(s), summer(s) or intersession(s) in which the material will be assigned (check all the apply)*

Fall 2021Wintersession 2022Spring 2022Summer 2022Fall 2022Wintersession 2023Spring 2023Summer 2023Fall 2023Wintersession 2024Spring 2024Summer 2024Fall 2024
Do you receive income in any form (royalties or other) from assigning these materials to your students? *
Please explain why you don’t receive any profit while your intellectual property is being sold to students at SCSU.*
Choose one of the following*

I am donating all profits to a 501(c)(3)I am donating all profits to the SCSU Foundation or a university fund.I am seeking a waiver from this policy to retain the profits from my intellectual property
Justification:*
Note: documented evidence is required to support justification, e.g. published reviews or publisher data of sales to other universities. A copy of this evidence and of the book/work must be submitted to Susan Westrick, Intellectual Property Chairperson, for committee review by Friday, November 1, 2019.
Name of 501(c)(3)*
Note: faculty members, their research, programs or departments cannot derive any financial gain or benefit from donations to the 501 (c)(3), including any personal tax donation benefit from the donation for the faculty member.
Your statement of how the profits will be donated*
Note: faculty members, their research, programs or departments cannot derive any financial gain or benefit from donations to the SCSU Foundation or university fund, including any personal tax donation benefit from the donation for the faculty member.
I certify that I am in compliance with all requirements as specified in the current SCSU Policy Concerning the Assigning of Faculty Authored Textbooks or Other Intellectual Property Taught by the Same Faculty.
Your Name / serves as an official signature*
Date*
A copy of your Notification and Compliance Form will be sent to the Chair of your department.

In every two (academic) years, all faculty who require their own students to purchase the faculty member’s intellectual property are required to resubmit the Notification and Compliance Form.

Note: if there are issues which fall outside the scope of this protocol, please notify the Provost office.
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