Request for an incoming or outgoing Material Transfer Agreement

A Material Transfer Agreement (MTA): is a contract, generally without funding, which provides a legal framework to govern the exchange of research materials between academic, government, and commercial organizations. The types of materials transferred under MTAs may include anything from software to cell lines, cultures, plasmids, nucleotides, proteins, bacteria, pharmaceuticals, chemicals, and other proprietary physical materials and transgenic animals. MTAs are important because they delineate the rights, obligations, and restrictions of both the providing and receiving scientists with respect to issues such as:

Please feel free to contact OSP with any questions you may have regarding MTA's.

* = Required fields

* Requesting UTHSC PI Name:
* Phone:
* 1. I am requesting materials
        I am sending materials
* 2. Please provide the Name of the Principal Investigator who will provide or receive the materials (the other party)
* Name:
* Institution:
* Address:
* City:
* State:
* Zip Code:
* E-mail:
* Phone:

If there is an administrative contact with whom we should be in contact please provide their:
Name:
E-mail:
Phone:
* 3. Name of the material being requested

4. What is the nature of the materials?
    Animal Model
    Antibody (monoclonal)
    Antibody (polyclonal)
    Protein
    Virus
    Cell Line
    Device (non-medical)
    Device (medical)
    Software (encrypted)
    Software (unencrypted)
    Plasmid
    Human Origin Sample
    Human Data
    Other
5. Please describe the use of the materials
* 6. Will confidential information be exchanged? Yes     No
* 7. What period may the materials be used for? No specific limit     For the duration of a specific project
8. Has the material been published? Yes     No
9. Do you anticipate that there will be any new inventions based on the use of the material(s)? Yes     No
* 10. Is this MTA related to a UTHSC invention? Yes     No
11. Will the materials be used in conjunction with any other materials used from other entities? Yes     No
12. Will the research involve (check as many as are applicable):
    Making derivatives
    Modifications
    Progeny
    Other substance
    Not applicable
13. Are you working with any hazardous materials (i.e. biohazards, including infectious agents, human or not-human primate cell lines, toxins, or radioactive materials? Yes     No
14. If you are providing the materials do you need to have the materials returned to you? Yes     No
15. Please upload any agreement form(s) of correspondence from the Outside Party:

Upload MTA Form
Upload correspondence/background information

* 16. Currently and during the proposed term of the DUA none of my family members have:
  1. A personal financial interest in this project or personal financial relationship (including compensation or gifts of cash or in-kind) with any entity involved in the study, including sponsor, vendors, subrecipients, or other interested parties (including investigator's family member participating in the project)?
    Yes     No
  2. A personal financial interest in or personal financial relationship (including gifts of cash or in-kind) with an entity that owns or has the right to commercialize a product, process, or technology studied in this project?
    Yes     No
  3. A board membership of any kind or an executive position (paid or unpaid) with the sponsor of this project or with an entity that owns or has the right to commercialize a product, process, or technology studied in this project or that is otherwise involved with the project?
    Yes     No


Certifications:
To the best of my knowledge the answers to the questions I have provided are true, complete, and accurate.

If you are requesting materials please also certify that: *PI (print name and title here): Date: