MATERIAL TRANSFER AGREEMENT (MTA) QUESTIONNAIRE
MTAs for Incoming Materials
JAMES MADISON UNIVERSITY (JMU)
OFFICE OF SPONSORED PROGRAMS (OSP)
This form can be downloaded from http://www.jmu.edu/sponsprog/allforms.html
You MUST fully complete and sign this form in order for us to process your MTA.
1. Principal Investigator Requesting Materials 7. Do you have a consulting relationship with the
Name: provider of the material?
Title: Yes No
Phone:
8. Is the Material available commercially or through
Email: any other source such as a Research Reagent Bank
or Depository (such as the ATTC, Hybridoma Bank,
2. Provider of Material and Provider’s Institution or etc.) Yes No
company
Non-profit/University 9. a. Explain how you will use the Material (attach of
Commercial Entity scope of work). Identify if used for preclinical
data or research tool and highlight the part
Name and Address of Organization: relating to the use of the material:
b. Is a unique animal model involved?
Yes No
If yes, who developed the unique model?
JMU
Contact person & phone # or e-mail address: Other
c. Does the use of the Material involve:
Animals? Human subjects? Please
attach IRB or IACUC approval document(s).
3. Agreement documents for requested materials.
Please attach any Agreement, Statement of d. Does the scope of work involve other JMU
Investigator Form, letter of intent, or correspondence employees or Graduate students?
of any kind between you and the Provider of the Yes No
Material stating any condition(s), restriction(s) or If yes, please identify.
guidelines under which the material may be used.
4. Type of Material (please define if necessary) e. Will materials be used by collaborators outside of
JMU?
Yes No
If yes, please identify.
5. Is the material encumbered by patent(s) or license(s)
of which you are aware?
Yes No
10. Corporate/Industrial Support
Explain:
Do you receive industrial support for any portion of
your salary or the salary of individuals working
under your supervision on the project I which the
6. Do you have the material in your possession? Materials will be used?
Yes No Yes No
(a) If yes, please identify the other material(s) and
Do you receive industrial support for the research
where it/they come from:
project in which materials will be used?
Yes No
Do you receive industrial support for purchase of (b) If yes, were there any Agreement, Statement of
supplies, reagents, animals, tissues or cells which Investigator Form, letter of intent or
will be used in the research project for which correspondence of any kind between you and the
materials are being requested? provider of the Other Material(s)?
Yes No
Yes No
If “yes” to any of the above, please explain briefly:
(c) If yes, and you have not already provided a copy
to OSP, kindly do so now.
If “yes” to any of the above, has the project been 13. Will the Material be used in conjunction with any
routed? Yes No other materials developed at JMU?
Will the provider participate in the research? Yes No
Yes No
Is the JMU material subject of a disclosure to Tech
11. Funding for the project in which the Materials Com., license, patent application, discussion with
will be used: Please list the sponsor(s) (for-profit, Tech Com?
Foundations, Federal, etc.) title of research project(s) Yes No
and, if appropriate grant number(s) of the on-going
sponsored research project(s) in which material will If so, identify the JMU employee who created the
be used. material.
14. Does the research involve any material or method of
Are you using material to generate preliminary data value or potential value that you have developed? If
for support of a grant application? If so, identify the yes, please describe and list relevant patents or
granting agency and the deadline. invention disclosures.
Yes No Yes No
12. Will the material be used in conjunction with any 15. Do you anticipate that novel, unique methods,
other material(s) or used in experiments involving materials, processes, ideas, technologies,
other materials obtained from a third party under compounds, research tools, screening devices,
another agreement (e.g., license, Sponsored therapies or diagnostics will be developed from the
Research, MTA)? If yes, please explain. use of the Material?
Yes No Yes No
Please be aware that there may be terms and conditions in the Material Transfer Agreement which may (i) preclude
your use of the Materials in research sponsored by third parties, or (ii) prevent you from obtaining Materials in the
future from third parties whose policies do not allow distribution of biological materials to investigators whose rights
to commercialized technology may be limited by pre-existing obligations. DO NOT RELEASE MATERIAL TO A
THIRD PARTY (INCLUDING JMU PERSONNEL) WITHOUT THE WRITTEN PERMISSION OF THE
PROVIDER.
I certify that all information provided is accurate.
Signature Date
Please send this completed and signed form with attachments to the Office of Sponsored Programs, by
fax to 540-568-6240 or email signed form with attachments to jmu_grants@jmu.edu.