(rev 7/11)
Boston University Medical Campus Material Transfer Agreement Information Sheet
Investigator Name: Department:
Phone: Fax: E-mail:
Provider Name: Provider Contact:
Phone: Fax: E-mail:
Name/Description of the Material:
Location of Research using Material will be conducted:
Description of Research to be conducted with Material:
PLEASE BE SURE TO READ CAREFULLY AND ANSWER EACH QUESTION IN ORDER TO
YES NO EXPEDITE THE REVIEW PROCESS.
Is your research with the requested Material being conducted in BU-owned space? (If BMC-owned space, send
1. the MTA to the BMC Grants Office.) http://www.bu.edu/osp/files/2010/03/OSPMEDspacematrix10609.xls
2. Is the Material to be used in living persons? If YES, research is not permitted under MTAs.
3. Is the Material rDNA? If YES, you must apply for IBC approval.
Is the Material biohazardous? (Biohazardous materials, infectious agents, select agents, human blood, tissues,
4. cells, cell lines.) If YES or you are unsure, you must apply for IBC approval.
Will you be modifying the Material? If so, how?
5.
Will you be creating any progeny? If so, please describe.
6.
Will the material by used in any research funded by the Provider? If so, please provide the sponsor(s) names(s)
and sponsored project number(s).
7.
Will the Material be used in any research project that is funded by industry sponsor(s) other than the Provider?
If so, please provide the sponsor(s) name(s), project title(s) and sponsored project number(s).
8.
9. How will you fund the research to be conducted with the material? Please provide grant/source number.
Will the Materials be used in conjunction with other Material from commercial parties? If so, what are these
other Materials and who provided them? Were Material Transfer Agreements signed for these other Materials?
10.
11. Is the Material commercially available for purchase?
12. Do you anticipate that any inventions will be developed from the use of the Materials? If YES, please discuss in
as much detail as possible.
Principal Investigator Certification: I certify that the information I have provided about this project is accurate.
Furthermore I certify that I will direct this project in compliance with Boston University policies, with the terms and
conditions of Boston University's Material Transfer Agreement with the Provider and with all applicable laws and
regulations.
Signature: Date:
For MTAs through Addgene, send completed form to: JLREVVY@bu.edu, or 617-638-4686 (fax)
For all other MTAs, fax the completed form, in WORD format, to: OSP Attorney, 617-638-4686 (fax)