Fillable Saint Louis University Material Transfer Request Form

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Saint Louis University Material Transfer Request Form

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00042245-1
Saint Louis University
Office of Technology Management
Material Transfer Request Form
1
Type of MTA
Is the agreement
(check one):
_____ Incoming
(the material is being received by SLU) – do not complete box 5
_____Outgoing
(the material is being provided by SLU) – do not complete box 6
2
Provider Information
Providing Scientist/PI name:
Providing Institution/Company:
Email:
Department:
Phone:
Mailing address:
3
Recipient Information
Receiving Scientist/PI name:
Receiving Institution:
Email:
Department:
Phone:
Mailing address:
4
Material Information
Material description
(name, amount to be transferred, etc.)
:
Brief description of the research in which material will be used:
(attach additional pages if necessary)
Is the material available
commercially or through any
other source such as a research
reagent bank or depository (ATCC,
Hybridoma Bank, etc)?
__no
__yes
EGFP or TET?
__no
__yes ____
____________
Is the material being used
with another material(s)
received under an MTA?
__no
__yes _________________
Source of other material
00042245-1
Is the material a human sample
(blood, serum, plasma, urine, stool, tissue,
etc.)?
__no
__yes _________________
IRB #
Are the samples de-identified?
___no ___yes
__no
__yes ____
_____________
IACUC #
Is the material a
recombinant DNA, infectious
agent or export controlled
agent?
__no
__yes
5
For Outgoing MTA
What is the source of funds under which the
materials were made?
__Federal ________________________________
__Foundation _____________________________
__Industry Sponsor _________________________
__Other __________________________________
Was the material created at SLU?
__yes
__no_____________________________________
(if no, identify the origin of the material and attach written
permission for transfer of the material)
Are you the creator/inventor of the material?
__yes
__no ________________________________
(if no, identify original creator/inventor)
If SLU material, has the material been disclosed to
the Office of Technology Management?
__yes________
__________
OTM #
__no (If no, please disclose the materials to the OTM using
t
he form here. Note: form will download immediately.)
Will the recipient pay for shipping?
__yes
__no
Will the recipient pay for the preparation of
the material?
__yes _______
_______________________
Preparation costs
__no
5
For Incoming MTA
What is the source of funds for the research in
which the material is to be used?
__Federal ________________________________
__Foundation _____________________________
6
00042245-1
__Industry Sponsor_________________________
__Other__________________________________
Will any modification be created out of the
material (substance that contains or incorporates
the material or is crossbred with your own
materials? __yes __no __unknown
Will any deriv
atives of the material be created?
__yes ___ no ___unknown
How long do you plan to use the materials?
______________________
__________
Do you intend to publish the findings of your
research using the materials?
__yes
__no
If yes, are y
ou willing to allow the provider a
chance to review a manuscript or other draft
publication in advance of submission?
___yes (choose one) days
___no
Do you have a financial interest in the provider
organization (income, consulting, stock ownership,
etc)?
__yes
__no
Have you been provided a draft MTA from the
provider?
__no
__yes
(attach a copy of the MTA with this form)
Provider Contact for contractual issues:
Name____________
___________
Email________________________
Phone________________________
90
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Saint Louis University Material Transfer Request Form

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Completed 25 March 2020

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