Form 902 V20170829

REQUEST FOR MATERIAL TRANSFER AGREEMENT

This internal request form is to be completed by the USU scientist and e-mailed to rior to sending research materials to, or when requesting research materials from, another institution. For questions related to this form, please email and a team member will respond. Please complete all sections.

Please place an “x” in the appropriate box;

Incoming Material Outgoing Material

When is the material needed: (month/year)

______

  1. USU Scientist Information:

Name:

Title:

Department:

Telephone:

E-mail Address:

  1. Other Party Contact Information:
  1. ScientistName:

Title:

E-mail address:

  1. Technology Transfer/Legal Office:

Contact Name:

E-mail address:

Telephone:

  1. Institution Name

Address:

  1. Material
  1. Specific material name(s) & description:

Amount needed:

  1. i) Is the Material of human origin? Yes No

ii) Is the Material to be used with patients? Yes No

iii) If yesto b(i) or b(ii) above, has IRB approval been received? Yes No

IRB Protocol #:**PLEASE PROVIDE A COPY OF THE IRB APPROVAL LETTER.

  1. Will the Material be used in animals or are animals being transferred? Yes No

Protocol # (if applicable): **PLEASE PROVIDE A COPY OF THE IACUC APPROVAL LETTER.

  1. Is this Material a select agent (as defined by National Select Agent Registry)? Yes No
  1. Is this Material subject to export control regulations? Yes No
  1. For Incoming Material, is this Material being purchased? Yes No

If the purchase requires an MTA, please list the cost, grant #, and grant title to be charged:

  1. For Outgoing Material, please provide the shipping address for the Material:
  1. Requested Use
  1. Provide a detailed description of the work to be performed using Material.
  1. What is the expected duration of the research?
  1. Potential for Invention

Note anypotential for new uses, new modifications of the material, new antibody or other reagent arising from this research with the Material.

  1. Third-Party Interests

Is therea third-party interest in any of the Material(s) to be used in this research plan?

Yes No

If yes, list the third party and briefly describe their interest.

  1. Is the Material related to another (current or potential) agreement (other MTA, CRADA, license, Clinical Trial, contract, subaward, etc.) with this party or another party?

Yes No

If yes, please describe and provide a copy of the other relevant agreement(s).

  1. Will this Material be used with USU proprietary material(s)?

Yes No

If yes, which ones? List first inventor name and approximate date of patent filing:

  1. Submission: Upon completion of this form, please send to .

Questions? Please email .

Thank you!

John W. Lowe Joint (USU-HJF) Office of Technology Transfer

Uniformed Services University / Henry M. Jackson Foundation for the Advancement of Military Medicine

Material Transfer Request Form

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