UNIVERSITY OF PITTSBURGH OFFICE OF RESEARCH (OR)

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

for University review and signature, Submit the following materialsby Email ()or fax (412/624-7414):

**completed submission form and any compliance documentation as requested below

The University of pittsburgh Office of Research will be the last signature affixed to any outgoing MTA

University Principal Investigator (PI) Contact Information:
Name:
Title:
Email: / Company/Institution Receiving Materials (Recipient):
PI’s Departmental Administrative Contact for MTA Follow-up
(not Office of Research Staff):
Name:
Phone/Email:
PI’s Department: PI’s Dept. ID: / Company/Institution Legal Contact for MTA:
Name:
Email/Phone:
Company/Institution PI/Scientific Name and Email:
  1. List ALL Material being provided under this MTA:
/
  1. Is this a biological Material?YesNo

General:

3.Was all the Material independently developed by you or under your direction at this University?

a. Yes
b. No, explain
4. Does the Material incorporate or is the Material derived from materials obtained from a third party.
a. Yes, explain
b. No
5. Was any of the Material brought to this University from somewhere else?
a. Yes, explain and provide applicable contact names/emails
b. No

6. Are there alternative sources to provide the Material?

Yes No
7. Is the Material under disclosure to or patented by the University Office of Technology Management (OTM)
a. Yes: OTM Staff Name
b. No

8. Is any of the Material related to any other agreements (including subcontracts) for funding and/or materials?

Yes No

If yes, list all that apply, i.e, Sponsored Research Agreement, Government or Other Grant , CDA, License, Subcontract, MTA, Other Agreement (list Company/ies)

Please provide Institution Number/Project Number or specific details for each

9. Do you require reimbursement for the cost to provide Materials*?

Yes – Please explain:No
Shipping only- via recipient entity UPS or Fed Ex account
* Costs charged must total exact costs spent to provide Materials.
10a. Do you require the recipient PI to share results back with you? Yes No
10b. Is this collaboration with the recipient? Yes No
10c. Do you desire joint publication of the resulting data?
Yes No /

Compliance:

11. Is the Material being sent to a recipient located outside of the United States?

Yes, specify country
No
Note: Shipments crossing state lines or leaving the country may require special shipping or handling permits from the:
USDA - or
CDC -

12. Is the Material of direct human origin?

Yes, attach applicable UPITT IRB/CORID letter of approval or exemption and applicable informed consent for your collection of materials

No
13.If human, will Materials be de-identified before shipping?
Yes No

14. Does the Material contain Human stem cells?

Yes, hSCRO registration or approval must be obtained prior to the MTA being signed. Please refer to the hSCRO Committee policies found at
No

15. Does the Material involve recombinant DNA?

Yes, attach applicable IBC/rDNA letter:

No

16. Is the Material on the federal Select Agent list?

Yes, attach applicable safety officer approval

No

Scope of Work:

[Enter here or attach Recipient Scientist’s scope of work using the Materials, which has been approved by Pitt PI]

To the best of my knowledge, the answers to the questions are true, complete and accurate. I have read the referenced MTA and agree to provide the Materials as outlined. I am a University of Pittsburgh faculty member authorized to oversee the transfer of the materials named above.
Principal Investigator: Date:

OR Outgoing MTA Submission Form (04/2006, Rev 07/2010, Rev 08/2012, Rev 11/2013)Page 1 of 1