MATERIAL TRANSFER AGREEMENT REQUEST FORM: INBOUND

INSTRUCTIONS: Please complete this form & submit to alongwith the Provider’s MTA if they sent you one. We cannot begin the review process until we receive this form. If you have any questions, please email or call 312-503-3897.

NORTHWESTERN PRINCIPAL INVESTIGATOR INFORMATION
NAME: / EMAIL:
Additional Contact Information (e.g. Research Administrator, Department/School Administrator, Postdoc, etc.)
CONTACT NAME: / CONTACT EMAIL:
ABOUT THE MATERIAL BEING REQUESTED
DESCRIBE MATERIAL(please be specific):
PROVIDING INSTITUTION OR COMPANY NAME:
CONTACT NAME: / CONTACT EMAIL:
Is the material of human origin or obtained from a human specimen?
If yes, is it completely de-identified (i.e. includes NO personal identifiers)? / YES NO
YES NO
**Note: If material is NOT completely de-identified, please send your IRB Approval Letter along with this form**
Will you receive any confidential information from the Provider about this Material?
Is the Material commercially available for purchase? / YES NO
YES NO
PLANNED USE OF MATERIAL
Will you be using this material in humans (e.g. drug treatment, diagnostic test)? YES NO
Will you be creating any modified versions of the Material? YES NO
If yes, please describe:
(Modifications include spliced/mutated gene sequences, transformed cells, cross-bred mice, etc.)
If the Material is being provided by a company, who initiated the transfer? Northwestern Company
Who wrote/will write the protocol for the intended experiments? Northwestern Company
Will the Material be used in conjunction with other proprietary materials from a third party (commercial or non-commercial)?
YES NO
If yes, what materials and what company/institution provided them:
Will the Material be used in conjunction with proprietary materials or other intellectual property of Northwestern University?
YES NO
Please identify any existing commitments made to third parties regarding this research project not already disclosed above:
SPECIFY FUNDING SOURCE(S) FOR THE PLANNED EXPERIMENTS USING THIS MATERIAL
Corporate. Please provide Sponsor Name here:
Federal Grant(s). Federal agency:

Non-federal Grant(s). Grantor Name(s):

Gift Funds. Giver Name(s):

Other. Please describe:

IF USING NIH FUNDING
If the NIH is the funding source for these experiments, does your grant require submission of any of the following?
An intellectual property management plan
Data sharing plan
Model organism sharing plan / If you checked yes to any of these, what is the SP# of your award? SP00
None of the above
EXPORT CONTROLS
Does this transfer involve the import of materials from someone in another country? YES NO
If yes, please confirm by checking the box below that the Material will be shipped in compliance with all applicable rules and regulations, including the U.S. export control regulations.
RESEARCH DESCRIPTION
Please enter a brief description (1-4 sentences) of your planned research using the requested material:

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