Form PTO PFH 001 PTO PFH 001 Humanitarian Use Application

PTO/PFH/001 (February 2022)

Approved for use through XX/XX/20XX. OMB Control Number 0651-0066

U.S. Patent and Trademark Office; U.S Department of Commerce

Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number.

Humanitarian Use Application

Applicant Contact Info:

Application Title:

Organizations Applying:

Primary Contact

Name:

Address:

Phone Number:

Email:

Alterative Contact Info:

Name:

Address:

Phone Number:

Email:

Primary Location of Applicants: City: State: Country:

Once received, contact information is detached from the application packet. The application packet is reviewed blind by the judges.

Patents for Humanity: Innovation in Response to COVID-19 Humanitarian Application Use Form

Q: Application Title

Q: Represent your entry with a photo, image, logo.

Preferred size is 640x480 pixels.

Q: Please verify your category *

Patent Information

List all relevant U.S. utility patents or U.S. patent applications you own or license that you wish to apply under. These patents must relate to the technology described in this submission. Only one U.S. patent or U.S. patent application is required for eligibility. If any U.S. patents or U.S. patent applications are found ineligible, the remaining items will be considered. If no eligible items remain, the USPTO may contact the applicants to determine if eligible material can be identified.

Patent 1 Information

Q: 1. Is this a U.S. Patent or U.S. Patent Application or PCT Patent Application?

Q: PCT Patent Application Number

Q: U.S. Patent Number, U.S. Patent Application Number or PCT Patent Application Number

Q: Please enter the Title

Q: Please enter the Issue Date or Filing Date

Q: Are any of these patents or patent applications licensed from an entity not listed as an applicant on this form?

Q: By checking yes, you are certifying the following statement: I have given a copy of this submission to the owner of each licensed patent covered by this application, and notified them of their ability to submit a supporting statement.

Q: Is this a Non-Provisional or Provisional patent application?

Q: If you have additional U.S. Patents or U.S. Patent Applications or PCT Patent Applications, complete the following. Otherwise, please skip to "Tell us your story".

Patent 2 Information

Q: 2. Is this a U.S. Patent or U.S. Patent Application or PCT Patent Application?

Q: U.S. Patent Number, U.S. Patent Application Number or PCT Patent Application Number

Q: Title

Q: Issue Date or Filing Date

Q: Are any of these patents or patent applications licensed from an entity not listed as an applicant on this form?

Q: By checking yes, you are certifying the following statement: I have given a copy of this submission to the owner of each licensed patent covered by this application, and notified them of their ability to submit a supporting statement.

Patent 3 Information

Q: 3. Is this a U.S. Patent or U.S. Patent Application or PCT Patent Application?

Q: U.S. Patent Number, U.S. Patent Application Number or PCT Application Number

Q: Title

Q: Issue Date or Filing Date

Q: Are any of these patents or patent applications licensed from an entity not listed as an applicant on this form?

Q: By checking yes you are certifying the following statement: I have given a copy of this submission to the owner of each licensed patent covered by this application, and notified them of their ability to submit a supporting statement.

Additional Patent Information

Q: Additional Patents: If you have any additional patents or applications, please add in the following information for each:

- U.S. Patent Number, U.S. Patent Application Number, or PCT Patent Application Number - Title
- Issue Date or Filing date

Tell us your story!

In no more than seven thousand characters, please address the following:

Q: What inspired your invention? How is it being used to help those impacted by COVID-19? How is it improving their lives? Be sure to point out how effective your technology is at addressing COVID-19, what actions you've taken to make the technology available for this purpose, and what impact it is having on people's lives. Please be sure to include any data that demonstrates your technology’s effectiveness at addressing COVID-19.

Additional Information

If there is any other information you would like the judges to consider, include it here. Judges are not required to read more than five pages of material, not including the first three pages of this form.

Q: Upload additional file here

Q: Upload video file here

Video Instructions:

• Keep file names under 30 characters
• Do not include special characters in file names.
• Once uploaded, your video will take some time to be rendered, depending on size. This can be anywhere from 30 seconds to a few minutes or longer.
• You will see a placeholder video in this spot while the video is processed.
• To check to see if your video is ready to be viewed, please refresh your page (you can do this by clicking the "Dashboard" icon).
• If you are uploading a very large file or using a slow internet connection, be aware that the system will time out after 60 minutes.

• Your video will need to be published before you can submit your application. You must be able to see your video rather than the placeholder video before you close your window or log out.

We strongly advise you do not try to upload your video right before the submission deadline.

Paperwork Reduction Act Statement

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995, unless the information collection has a valid OMB Control Number. The OMB Control Number for this information collection is 0651-0066. Public burden for this survey is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to the Office of the Chief Administrative Officer, United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450 or email InformationCollection@uspto.gov.

Privacy Act Statement

The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with your submission of the attached form related to a patent application or patent. The United States Patent and Trademark Office (USPTO) collects this information under authority of 35 U.S.C. §§ 1-2. The information in this system of records is used to manage all records of applicant including name, citizenship, residence, post office address, and other information with respect to inventors and their legal representatives pertaining to the applicant's activities in connection with the invention for which a patent is sought.

This information is protected from disclosure to third parties in accordance with the Privacy Act. However, routine uses of this information may include disclosure to the following: to law enforcement for investigation in the event that the system of records indicates a violation or potential violation of law; to a Federal, state, local, or international agency, in response to its request; to an agency, organization, or individual for the purpose of performing audit or oversight operations as authorized by law; to non-federal personnel under contract to the agency; to a court for adjudication and litigation; to the Department of Justice for Freedom of Information Act assistance; to members of Congress working on behalf of an individual; to the Office of Personnel Management for personnel research purposes; to National Archives and Records Administration for records management; and to the Office of Management and Budget for legislative coordination and clearance. Failure to provide any part of the requested information may result in an inability to process applications or requests for access and information. The applicable Privacy Act System of Records Notice for this information is COMMERCE/PAT-TM-7 Patent Application Files, available in the Federal Register at 78 FR 19243 (March 29, 2013). https://www.govinfo.gov/content/pkg/FR-2013-03-29/pdf/2013-07341.pdf