Midwestern University MTA Request Form - Outgoing

Office of Research Sponsored Programs

Check One: for Clinical Investigation / Trial Send completed forms to

for Non-Clinical Research

Other

A fully executed MTA must be completed by the Office of Research Administration or Sponsored Programs

prior to shipping any materials to Recipient.

Midwestern University Provider Scientist: / Phone: / Email:
Material(s) requested and quantity:
Recipient Scientist:
Phone:
E-mail:
Fax: / Recipient Institution:
Mailing Address:
(If known)
Contact Person:
Phone:
E-mail:
Fax:
Do you want to charge the Recipient a fee for transfer
of the Material: Yes No / Did you identify an account to cover associated charges: Yes No N/A
Material is: (Check all that apply)
Live vertebrate animals
Human materials (including tissues, blood, blood products, bodily secretions or fluids, cell lines)
Nonhuman primate materials (including tissues, blood, blood products, bodily secretions or fluids, cell lines)
Human stem cells Animal stem cells
Recombinant DNA
Transgenic animals plants seeds
Biotoxins / Pathogens human animal plant
Biological hazard
Pyrophoric gases
Extremely toxic gases
Explosives
Dioxins
Export controlled (ITAR/EAR)
Other (specify):
Provide information on any special handling, regulatory or storage issues with this Material: (Please explain)
How will the Material be shipped or transported?
Is the Recipient paying for shipping fees? Yes No
Is this a re-transfer of Material received from others? Yes No
If yes, who was the original Provider? Approximate date received:
Were the Materials originally transferred under an MTA? Yes No
Was the Material developed with federal funding? Yes No
If yes, is the project currently active? Yes No
If yes, please specify the agency and grant number:
Does the Material contain materials received from others? Yes No
If so, please provide specific details.
Is the Materials derived from materials received from others? Yes No
If so, please provide specific details.
How would you prefer the Recipient dispose of the Material?
Return to Midwestern University / your laboratory
Destroy in accordance will all applicable laws and regulations
Use at their discretion
Other:
Yes / No
Does the Material / MTA relate to any invention disclosure, patent application, or patent made to or filed by Midwestern University or another institution in relation to your work? If yes, provide title:
Are you or Midwestern University receiving any funds from the Recipient (gift, contract or otherwise)?
Do you have a financial relationship of any kind with the Recipient?
If yes, provide an updated Conflict of Interest/Commitment Disclosure–for the named entity.
If you are shipping mice or other vertebrate animals, have you contacted Heather Brady (Glendale) Joanna Kammholz (Downers Grove), Midwestern University’s Animal Care Tech.? Written approval must be obtained from Office of Research & Sponsored Programs and the Veterinarian before shipping any mice or vertebrate animals.
Are you are shipping human material,
Is the Material the subject of an FDA application, or is it regulated by the FDA?
Midwestern University Provider Scientist Signature
I certify that the information provided in this MTA Request Form is true and accurate. I understand that the Office of Research & Sponsored Programs may need to negotiate the terms of the MTA with the Recipient.
Signature: Date: ______

DELIVER THIS COMPLETED FORM to the appropriate office:

Office of Research & Sponsored Programs– ATTN: Maribeth Ackzen
Email:
Fax: (623) 572-3730 Phone: (623) 572-3769 / Office of Research & Sponsored Programs –ATTN: Jim Woods Email:
Fax: (623) 572-3498 Phone: (623) 572-3444