INTERNAL SUBMISSION FORM FOR THE REVIEW OF OUTGOING MATERIAL TRANSFER AGREEMENT (MTA)

Basic Information

1. / Principal Investigator:
2. / Department Administratively Responsible for this Agreement: / Department/Institute/Center Name:
Department/Institute/Center ID:
4. / Title of Submission:
5. / Department Administrative Contact for PI Name:

Contracting Party Information[1]

1 / Contracting Party Name:
2. / Legal Contact Name:
3. / Legal Contact E-Mail Address:
4. / Legal Contact Phone Number:
5. / Scientific Contact Name:
6. / Scientific Contact E-mail:
7. / Does the Principal Investigator have a financial relationship with any of the Contracting Parties listed above that is or should be disclosed on your University of Pittsburgh Conflict of Interest disclosure form? / Yes
No
If Yes, please explain:

Material Information

1. / Identify all materials being shared under this MTA:
2. / Do these contain biological material? / Yes
No

Material Source Information

1. / Was all material independently developed by you or under your direction at Pitt? / Yes
No
If no, please explain:
2. / Does the material incorporate or is the material derived from materials obtained from a
Third party? / Yes
No
If Yes, please explain:
3. / Was any of the material brought to Pitt from somewhere else? / Yes
No
If Yes, please explain:
4. / Are there alternative sources to provide the material? / Yes
No
If Yes, please explain:
5. / Is the material under disclosure to or patented by Pitt Office of Technology Management
(OTM)? / Yes
No
OTM Staff Member:
OTM Case Number:
6. / Are there any other agreements/funding/materials applicable to your research (List all
that apply, i.e., Sponsored Research Agreement, Government or Other Grant, CDA, License,
MTA, Subcontract, Other Agreement)? / Yes
No
If Yes, please provide the Institution or Project Number(s):

Material Recipient Information

1. / Do you require reimbursement for the cost to provide the material? / Yes
No
If Yes, please explain:
2. / Do you require the recipient to collaborate, share results or anticipate that they will jointly
publish with you? / Yes
No
If Yes, please explain:
3. / Attach the recipient's Scope of Work describing their use of the material as approved by
Pitt PI or enter it here: / Recipient SOW:

Export Control Information

1. / Do you have any reason to believe that the Material to be shipped may support: (1) the
design, development, production, stockpiling or use of a nuclear explosive device, chemical
or biological weapons, rockets/missiles, or space launch vehicles OR (2) a Chinese military
end-use OR (3) an illegal activity? / Yes
No
If Yes, please explain:
2. / Do you have knowledge that the item or information will be used on a foreign vessel or
aircraft? / Yes
No
If Yes, please explain:
3. / Does the Material have any military, intelligence or nuclear applications? / Yes
No
If Yes, please explain:
4. / Has anyone informed you that the Material is export-controlled under the US export control
regulations? / Yes
No
If Yes, please explain:
5. / Is the Material a chemical or biological agent as set forth in the Australia Group Common Controls List ( / Yes
No
If Yes, please explain:
6. / Is the Material a toxicological agent listed in the Matrix - ITAR toxicological agents? ( / Yes
No
If Yes, please explain:
7. / Are you shipping the Material to a location outside the United States or to a foreign entity within the United States? / Yes
No
If Yes, please provide:
Address:
Country:

Compliance Information

1 / What is the origin of these materials? / Human
Animal
Plasmid
Other or Unknown
If Other of Unknown, explain:

Human OriginInformation( Not Applicable)

1. / IRB Approval / Please attach IRB Approval Letter and Informed Consent
2. / Is the Material taken from a decedent (cadaver)? / Yes
No
If Yes, please attach CORID letter of approval.
3. / Does the material contain human stem cells? / Yes
No
If Yes, please attach hSCRO letter of approval.
Are the human embryonic stem cells on the NIH stem cell registry? Yes No

Animal OriginInformation ( Not Applicable)

1. / Is the material a live animal? / Yes
No
If Yes, please attach IACUC letter of approval.

Other Compliance Information

1. / Does the material or research with the material involve recombinant or synthetic nucleic acid molecules? / Yes
No
Is IBC Approval pending? Yes No
If no, please attach approval letter.
2. / Does the material require Radiation Safety Office approval? / Yes
No
Is Radiation Safety Office Approval pending? Yes No
If no, please attach approval letter.
3. / Is the material on the Federal Select Agent list? / Yes
No
Is EH &Safety Approval pending? Yes No
If no, please attach approval letter.

Additional Information

1. / Additional information relevant to the review of this request, including any time constraints:

Submit the requested materialsby Email to

All fields on this form are required.

Forms missing information or submission packages that do not include requested documentation will be returned to the submitter.

Form Revision Date: 11/2014

Page 1

[1] If there are multiple contracting parties for this agreement, please attach a list (including legal contact information) to your submission package.