INCOMING MATERIAL TRANSFER AGREEMENT REVIEW FORM

This form has been updated on 26 November 2014. It supersedes ALL previous versions.
Office of Research Administration
INCOMING MATERIAL TRANSFER AGREEMENT REVIEW FORM
Please complete this form, including signatures by Principal Investigator (PI) and Department Chairperson/Director of administering unit.
Send the completed and signed copy and all necessary documentation to ORA. Call 301-405-6269 for assistance.
1. Principal Investigator
Name
2. Administering Department
3. Alternate Contact
Name
Phone
Email
Phone
Email
4. Provider Organization
Address
Website URL
5. Provider Scientist
Name
Phone
Email
Name
Phone
Email
6. Provider Contractual/Administrator
ORA must have the Provider’s Contractual contact information to proceed. MTAs cannot be negotiated by Provider Scientists.
7. ATTACH DOCUMENTS FOR REQUESTED MATERIALS: Please attach any Material Transfer Agreement, Statement of
Investigator Form, Letter of Intent, or any other documents or correspondence of any kind between you and the Provider of the Material(s)
stating any condition(s), restriction(s), or guidelines under which the Material(s) may be used. Use the space provided below to include any
notes about the organization, such as a web address or if they use electronic MTA forms.
Material and Project Information
8. What is the material?
Provide a description of how the material(s) will be used. Attach additional pages as necessary.
9. What source(s) of funding, including award number(s), will be used to support the research?
KFS or Award #1
KFS or Award #2
KFS or Award #3
10. How long will you use the material(s), e.g., 2 years?
Begin Date
End Date
11.
Yes
No
Will the material(s) be used in conjunction with other materials received from a third party?
If yes, please list other materials and providers.
12.
Yes
No
Are the materials relevant to any previous, pending, or future disclosures of intellectual property to
the Office of Technology Commercialization (OTC)? If yes, list all that apply.
13.
Yes
No
14.
Yes
No
15.
16.
Yes
Yes
No
No
Do you intend to commercialize the results of research stemming from the use of the material(s) or
any modified derivatives of the material(s)?
Has any confidentiality of nondisclosure agreement from the provider been signed in connection with
the material(s)?
Do you have the material(s) in your possession?
Is the material available through any other source such as a Research Reagent Bank or Depository (e.g.,
ATCC or Hybridoma Bank)?
For ORA Use Only:
Proposal Development Number:
Institute Proposal Number:
Material and Project Information Continued
17. Check all that apply:
A.
The material(s) will be provided for the purpose of product testing and evaluation (e.g., testing an
expression system) for the providing organization.
B.
The materials are a tool, kit, or instrument that will be used in the conduct of research.
C.
The material is a reagent.
D.
Progeny, unmodified derivatives, or descendant copies will be made from the material(s).
E.
The material(s) will be modified or will be used to produce modified derivatives.
F.
The material(s) will be used in another manner. Please explain:
18a.
18b.
Yes
No
Human subjects: Will this research include using Human Subjects?
If yes, has an IRB application been submitted to the IRB office?
Yes Please provide the title used on the IRB application and the IRB protocol approval number.
No
19a.
19b.
Yes
No
Animal subjects: Will this research include using vertebrate animals?
If yes, has an IACUC protocol approval number been assigned?
Yes Please provide the title used on the IACUC application and the IACUC protocol approval number.
No
20a.
Yes
No
20b.
21.
Yes
No
An IRB application has not been submitted for this project but will be if this project is awarded.
Submit one copy of the proposal protocol form to the IRB Office. For more information,
contact the IRB office at [email protected]
An IACUC application has not yet been submitted for this project. For more
information, contact the IACUC Coordinator at x55037 or [email protected] .
Radioactive Materials: Will radioactive materials or ionizing radiation producing devices be used in
this research? Includes x-ray units, electron microscopes, and particle accelerators; non-ionizing
radiation producing devices such as lasers, IR, UV, or other optical emitting devices, and/or microwaves,
RF, or electromagnetic sources of radiation.
If yes, will these devices by
ionizing and/or
non-ionizing radiation producing?
Maryland Department of the Environment (MDE) requires radiation safety training and an approved
authorization prior to the use of such devices. Call DES, x 53960, for assistance.
Genetically engineered organisms: Will genetically engineered organisms be used or produced in
this research? If yes, please explain.
Biological materials: Will this research use biological materials? E.g., recombinant DNA or RNA, human
pathogens, toxins, or blood, unfixed tissue, or primary cell culture derived from humans or non-human
primates. Call DES, x 53960, for assistance.
23.
Yes No
Chemicals: Will this project require the use of chemicals? If this project includes the use of
chemicals, a Chemical Hygiene Plan and training is required. Call DES, x 53960, for assistance.
24.
Yes No
Select Agent Toxins: Will this research require the use of one or more select agent toxins? A list
of select agents can be found here: http://www.selectagents.gov. Call DES, x 53960, for assistance.
25.
Yes No
Export Controlled Material: Has the transferor indicated that the material is export controlled, or do
you suspect that the material may have been designed for a military application? If yes, contact
Export Compliance Office, [email protected] or x 52656, to determine whether any special
controls are required for handling and storage of the material.
26.
Yes No
Conflict of Interest: Is there a real or potential conflict of interest in connection with this work
involving a University of Maryland employee, as defined by the University of Maryland Policies and
Procedures II-3.10(A) or II-3.10(B)? If yes, a disclosure form must be completed and submitted in
accordance with these procedures.
For more information on COI, refer to http://www.umresearch.umd.edu/RCO/
By signing this form, I certify that the foregoing is true and correct to the best of my knowledge, and I agree to comply with current
University policies and Federal Regulations.
Principal Investigator
Date
22.
Yes
No
Department Chair
Date
Division of Research/ORA
Date
ORA Use only:
Remarks:
Reviewed by:
Date