MTA Application Form

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Requests formaterials with/without associatedinformation from Queensland Health Forensic and Scientific Services

Name: / Date:
Position: / Telephone no:
Organisation: / Fax no:
Address: / Email address:

1. Please indicate the purpose for which this request is being made? (tick all that apply)

a. Research (e.g. publication)f. Other: (Please specify)

b. Commercial development

c. Public health study

d. Process improvement

(e.g. method development)

e. Quality Activities

(Eg, quality control, audit)

2. Please indicate the original source of the material requested:

a) Human:
Patient Volunteer Coronial autopsy Non-coronial autopsy
b) Animal:
Laboratory Wild
Please specify:
c) Plant:
Please specify:
d) Insect:
Please specify:
e) Environment:
Food Soil Water
Please specify:
f) Laboratory:
Culture Cell culture
Please specify:
f) Other: Please specify:
g) Unknown: Please specify:

3. Please indicate the type of the initial material requested where applicable?

BloodBacteria

UrineVirus

TissueDNA

SerumOther: (Please specify)

Antiserum

Ascitic fluid

4. Please give details of the material requested where applicable?

(e.g.DNA from blood, inactivated antigen or cell culture supernatant from virus types)

5. Please indicate the quantity of materials requested e.g. number / volume?

6. Please indicate the frequency and duration the materials will be required?

7. On completion, materials supplied will be:

Retained Period of retention:

Disposed of

Returned to Queensland Health Forensic and Scientific Services

8. Please specify what information you require about the materials requested?

9. If the source of the material is human, is the identity of a specific individual able to be ascertained from this information? (Eg. name, address, date of birth)

Yes (go to question 10) No (go to question 11) Unknown (go to question 11)

10. Please specify the reasons the identifying information is required?

11. Please specify how the privacy of the individual will be protected?

12. Please provide a detailed description of the intended useof the materials requested and if applicable the associated information:

13. Is the intended use related to the original purpose for which the request was submitted?

Yes No

Important:

a)If the materials requested are subject to Department of Agriculture and Water Research (DAWR) Biosecurity Regulations a transfer permit will be required prior to the transfer of goods. In addition if the material is to be sent overseas, it may require a permit from the Department of Defence.

b)If this request is accepted, materials will be provided on the terms of Forensic and Scientific Services’ standard Materials Transfer Agreement (copy attached). This request constitutes an offer to receive the materials on those terms, and the officer who signs this form represents that he or she has authority to bind the requesting organisation to those terms.

14. Details of dangerous goods approved courier or forwarding company must be supplied:

Signed for and on behalf of:...... (organisation)

Name:……………………………………………………………….

Role:...... ……………….

Signature:...... ……………….

Date:...... ……………….

Please submit your application to:

Queensland Health Forensic and Scientific Services

POBOX 594 Archerfield QLD 4108

MTA Coordinator

Ph: (07) 3096 2990 Fax: (07) 3096 2977

Email:

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Document Number: 27773