Confidential Disclosure Agreement (CDA) Questionnaire

Confidential Disclosure Agreement (CDA) Questionnaire

MSU Technologies

Michigan State University

325 East Grand River, Suite 350

East Lansing, MI 48823

Submit this completed, signed form to the MTA/CDA Coordinator for the preparation or review of a CDA

(Submit by e-mail to or by FAX to 517-432-3880)

If you have questions please contact the MTA/CDA Coordinator by e-mail at or phone at 517-355-2186.

If you’ve received the other party’s CDA, please send it with this completed Questionnaire.

Incomplete Questionnaires may slow down the agreement review process

MSU Information:
Principal Investigator:
Title:
Department:
Phone:
E-mail Address:
Person initiating CDA
(if not PI)
Title:
Phone:
E-mail Address: / Other Institution/Company Name:
Address (if available):
Name of Principal Investigator:
Title:
Phone: E-mail Address:
Name of Contact: (If different than PI)
Title:
Phone: E-mail Address:
Legal Contact (if available):
Title:
Phone: E-mail Address:
Contact information another party (if a multi-party agreement):
Other Institution/Company Name:
Address (if available):
Name of Principal Investigator:
Title:
Phone: E-mail Address:
Name of Contact: (If different than PI)
Title:
Phone: E-mail Address:
Legal Contact (if available):
Title:
Phone: E-mail Address:

In order to appropriately evaluate the proposed CDA, please provide answers to the following questions. You may use additional sheets if you require more space for your answers.

INFORMATION:

1)Is this a mutual disclosure/exchange of confidential information? YESNO

If this is a one-way disclosure, please indicate if you are receiving or providing confidential information: Receiving Providing

2)If providing information, please provide a description of theconfidential (unpublished) information you’ll be providing that should be covered by this CDA:

3)What is the purpose of the discussions (for example, potential sponsored research project, potential license agreement, testing agreement, service agreement):

4)If samples need to be exchanged in relation to the discussions, please include a description of the samples:

5)Will there be a publication as a result of these discussions? YESNO

6)If this is for a grant proposal, please provide the name of the proposal and submission deadline:

7)Is there a potential meeting date for these discussions? YESNO

8)Is this related to a disclosed MSU invention or patent?

YESNO

If yes, please provide the name/ID number of the MSU invention or patent

9)If students areinvolved in the project,will this work be part of a thesis?

YESNO

FUNDING: (this area cannot be left blank)

1)If this is for a project funded by industrial or foundational sponsors, please provide the sponsor(s) name(s) and the applicable account or grant number:

2)If this information be used in any government funded research project, please provide the department(s) or agency(s) and the applicable account or grant number or application number:

3)Other, provide information about the funding source:

(Note: please include funding sources for those students and/or post-docs who will be working on the research.)

Feel free to add any additional information that you believe to be pertinent.

I am the Michigan State University faculty member authorized to oversee the disclosure or receipt of confidential information.

Principal Investigator’s Name: Title:

Principal Investigator’s Signature:Date:

Note: Without signature, this CDA questionnaire cannot be processed. E-mail from the Principal Investigator’s email account will substitute for signature.

Thank you for your cooperation in completing this questionnaire.

October 2016