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:

* 1. Please provide the Name of the Principal Investigator who will provide or receive the materials
* 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:
2. Name of the material being requested

* 3. I am requesting materials
        I am sending materials
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. Will the materials be used in conjunction with any other materials used from other entities? Yes     No
11. Will the research involve (check as many as are applicable):
    Making derivatives
    Modifications
    Progeny
    Other substance
    Not applicable
12. 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
13. If you are providing the materials do you need to have the materials returned to you? Yes     No
14. Please upload any agreement form(s) of correspondence from the Outside Party:

Upload MTA Form
Upload correspondence/background information

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:

I certify that I have read the referenced Material Transfer Agreement and understand and agree to abide by the terms it includes.

I take responsibility for ensuring that this certification will be upheld by any of the individuals who will have access to or use the materials.

I agree to use the materials in accordance with this Agreement

I will not transfer the materials to another entity outside of UTHSC without first obtaining prior written approval from the material provider.