Internal Submission Form for the Review of Incomingmaterial Transfer Agreement (Mta)

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

Basic Information

1. / Principal Investigator:
2. / Department Administratively Responsible for this Agreement: / Department/Institute/Center Name:
Department/Institute/Center ID:
3. / Should Pitt Generate the first draft of the agreement? / Yes
No (if no, please attach a draft agreement for review)
4. / Title of Submission:
5. / Department Administrative Contact: / Name:
E-Mail:

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
3. / Is the Material commercially available? / Yes
No

Funding Information

1 / Funding status of the research using the material(s): / Funded Award
Grant under consideration for funding
Proposal under development
Other - If Other, explain:
2. / Is the source of funding: / Internal (e.g. departmental or start-up funding)
External (e.g. sponsored research)
3. / Indicate the funding source (providing funds or considering providing funds): / Funding Source:
Grant Identifier/Award #:
PI of Grant Funds:
Are Funds Housed a Pitt? Yes No
If no, where are funds housed?
4 / Are there any other agreements/funding/materials applicable to your research (consider all that apply, i.e., Sponsored Research agreement, Government or Other Grant, CDA, License, MTA, Subcontract, Other Agreement)? / Yes
No
If Yes,
Institution Number:
Project Details:

Material Use Information

1. / Provide a concise scientific description of your use of material (or, attach a summary of your research):
2. / Is this Material intended to be: / Control/Tool
Other
If Other, explain:
3. / Will the material be modified? / Yes
No
4. / Will the material or modified material become incorporated into a new research material
(includes cross-breeding of mice)? / Yes
No
5. / Will the material be used in human subjects? / Yes, attach IRB approval letter or IRB Approval Pending
No
6. / Will the material be used in animals? / Yes, attach IACUC approval letter or IACUC Approval Pending
No

Material Location Information

1. / Describe the locations and laboratories at Pitt where the material will be used:
2. / Will your research use the Regional Biocontainment Laboratory (RBL) in BST 3? / Yes, attach RBL Approval Letter
No

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 / Yes, attach IRB approval letter or IRB approval Pending
No
2. / Is the Material taken from a decedent (cadaver)? / Yes, attach CORID approval letter or CORID approval Pending
No
3. / Does the material contain human stem cells? / Yes, attach hSCRO letter of approval or hSCRO approval pending
No
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, attach IACUC approval letter or IACUC approval pending
No

Other Compliance Information

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

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

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