SEND COMPLETED FORM TO: INDUSTRIAL CONTRACTS OFFICE

Phone: 3-0651  Fax: 5-7295  E-mail:  Mail Code: 1850

EquipmentLoanAgreementIntakeForm

Department: / PI: e-mail: phone:
Lab Contact: e-mail: phone:
Admin: e-mail: phone:
Name of Equipment / Manufacturer / Model / Serial #: / Project Title / Objective:
Lender Company:
Lender Contact (name, phone, e-mail):

Special Instructions:

Where will the equipment be installed: Stanford University, SHC or LPCH?
If the answer is SHC or LPCH, please provide the following information:
  1. SHC or LPCH equipment contact person (name, phone, e-mail):
  2. Department/location in SHC or LPCH where equipment will be installed:

Will the equipment be installed in areas where patients are located?
Will equipment be used for research purposes? If YES, provide an estimate of % time:
Will equipment be used clinically? If YES, provide an estimate of % time.
What is the start and end date of the equipment loan?
Who will install and/or pay for installation of the equipment? Who will de-install and/or pay for the return of the equipment? Who will pay for maintenance during the loan period?
What is the estimated total value of the equipment?
Will Stanford University, SHC or LPCH receive ownership of or rights to purchase the equipment? If YES, explain how the transfer will be carried out.
Will the equipment be used for research with human subjects? If YES, provide your IRB protocol #______
Will the equipment be modified after installation? If YES, how will it be modified and who will be responsible for such modification?
Will the loan of equipment include software?
Will the software be used for research purposes? If YES, provide an estimate of % time.
Will the software be used clinically? If YES, provide an estimate of % time.
Will the software be modified? If YES, how will it be modified and who will do the modification?
FDA approval: A. Has the equipment/software been approved by the FDA?
  1. Will the equipment/software be used here as approved by the FDA?
  2. If the equipment/software is not FDA-approved and will be used for human subjects, will you (PI) be the Sponsor? Who will hold the IND for the equipment/software in that case?

Specify the funding source(s) for the research conducted with the equipment (check all that apply):
Industry sponsor(s):
Government contract(s) or grant(s):
Nonprofit grant(s):
Gift funds (describe):
Other (describe):
Have all participating Stanford researchers who are currently identified, including postdocs, students and visiting scholars, signed Stanford’s Patent and Copyright Agreement form (SU-18 or SU-18A)?
Do any of the participating Stanford researchers have a financial relationship with the Lender such as consulting, serving on an Advisory Board or Board of Directors, or ownership of stock or stock options? If YES, describe:
Have any of the involvedStanford researchers received gift funds from the Lender?
PI Certification
I certify that the information I have provided about this project is accurate. Furthermore, I certify that I will direct this project in compliance with Stanford University policies, with the terms and conditions of Stanford’s agreement with the Provider, and with all applicable laws and regulations and will uphold the responsibilities of PIship.
PI Signature: Date:
University Department Approvals
As Chair of this department I have reviewed and approve receipt of this equipment.
Signature: Date:
SHC or LPCH Approvals (if applicable)
I, as ______[insert title], have reviewed and approve receipt of this equipment.
Signature: Date:

Updated: 10/17/2018