Technology Partnerships OMBudsmen Reporting Requirements

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FY 20

QTR
1st
2nd
3rd
4th
No Quarterly Activity

This form is to be completed by the TTO for individual inquiry/case activity during the quarter as required
by the Technology Transfer Commercialization Act of 2000. Mouse over definitions and descriptions
appear over text/check boxes where appropriate. After completing this form, click on the submit button.
*If you have no TTO activity for the quarter, please fill in your name, FY and quarter, lab or facility and check the box
“No Quarterly Activity”.

Initial Ombuds Contact: ____________________
Ombuds Name: __________________________
Final Ombuds Involvement: _________________
Laboratory or Facility:
AMES
INL
LLNL
NNSS
PPPL
TJ

ANL
KCP
NBL
ORNL
SLAC
Y-12

Type:
Inquiry
Case
Time Spent: (Hours) ______________

BNL
LANL
NETL
PXSO
SNL
FERMI

Source of Inquiry/Case:
Private Industry
Not-for-Profit
Lab/Facility Employee

LBNL
NREL
PNNL
SRNL
Other ____________

Office Personnel
Self-Identified Small Business
Private Individual
Other ____________

Subject of Inquiry/Case:
CRADA
Invention

License
WFO
Other ____________

Nature of Issue(s):
Policy Interpretation
Termination of Contract
Royalties
Rights to Intellectual Property

Terms & Conditions
Manufacture Issue
Expiration of Patent/License
Unfair Competition

Procedures
Process Status
General _________________

Actions:
Consultation/”Sounding Board”
Externally Mediated
Referred to ____________________
Other ____________
TTO Mediated/Facilitated between TTO visitor and _________________________
Quarterly Status or Outcome:
Pending from __________ FY Qtr __________
Resolved

Unresolved
Other ____________

Optional Case Notes:

Email to: OfficeofConflictPreventionandResolution@hq.doe.gov
Phone: (202) 586-6972 or (202) 586-4002

OMB Control No.: 1910-5118
Expiration Date:

U.S. Department of Energy
OMB Burden Disclosure Statement
This data is being collected pursuant to the Technology Transfer Commercialization Act of 2000, Pub. L.
106-404, codified at 42 U.S.C. 7261c (c) 3 (C). The data supplied will ensure that the Technology
Partnership Ombudsmen are hearing and helping resolve complaints from outside organizations
regarding the policies and actions of the national laboratory or facility with respect to technology
partnerships.
Public reporting burden for this collection of information is estimated to average 15 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to Office of the Chief Information Officer, Records Management Division, IM-23,
Paperwork Reduction Project (1910-5118), U.S. Department of Energy, 1000 Independence Ave SW,
Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork
Reduction Project (1910-5118), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person
be subject to a penalty for failure to comply with a collection of information subject to the requirements of
the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control
number.
Submission of this data is required pursuant to the Technology Transfer Commercialization Act.