Template Version Xx/Xx/Xx

FORM FRM5610/1 Effective:13/10/16

WORK REQUEST FORM RESEARCH AND DEVELOPMENT PROJECTS

INSTRUCTIONS

. For Confidentiality Agreements, please complete Project Details and Section A.

. For all other types of contracting support, please complete Project Details and Section B.

. If the contract is to include financial transactions, please arrange for the Finance Business Partner to approve Section C.

. Completed forms should be submitted to the R&D Office ( research.office @nhsbt.nhs.uk).

. The R&D Contract Manager will contact you within 7 working days to have a consultation call with you and generate a plan for the request.

PROJECT DETAILS Project Lead:

Project Title:

Project Purpose (a brief description without acronyms):

R&D Reference (if applicable):

ACTION REQUESTED

Drafting of new agreement Review of customers agreement Amendment to existing agreement. Other (please state)

For each Party:

Company Name & Address:

Contact details for Contract Representative (name, phone and email address):

Contact details for Project (name, phone and email address): Lead

[Please copy, paste and complete the above for each Party involved in the Contract.]

(Template Version xx/xx/xx)

Cross-Referenced in Primary Document: MPD1284 Page 1 of 4 FORM FRM5610/1 Effective:13/10/16

SECTION A – CONFIDENTIALITY AGREEMENTS

Proposed Confidentiality Agreement Start Date:

Has the other Contracting Party provided its own agreement for review? Yes No

If Yes, please attach the agreement to this form. If No, the R&D Contract Manager shall provide the Contracting Party(s) with NHSBT’s template agreement.

Please note, the desired starting position is to use NHSBT’s own template, as this will significantly reduce the time it takes to review and execute the confidentiality agreement.

SECTION B – ALL OTHER CONTRACTING MATTERS

GENERAL INFORMATION

Proposed Contract/Project Start Date:

Proposed Contract/Project End Date:

Is this a new Contracting Party for NHSBT? Yes No

Is this a new Project for NHSBT? Yes No

Does NHSBT have contract(s) already in place for this Project/Party? If yes, please provide further details and include any reference numbers.

Please provide details of how NHSBT’s involvement in the project has been approved and provide any supporting documentation, to be listed at the end of this section. For example, is NHSBT acting as Sponsor of the study or has it been discussed at the relevant Senior Management Team Meeting or Strategy Group, etc.:

What approval has been sought (including MHRA, HRA, and ethics approval)? Please attach any letters confirming approval from the REC.

Do you expect NHSBT to generate any Intellectual Property during the course of the project?

Are there any arrangements to manage any IP?

What strategy has been agreed to manage IP?

CONTRACT SPECIFICATION

Please provide extensive detail of the specific information to be included within the contract.

What is NHSBT providing? If this is a specific item or amount, please provide details such as volumes or types.

What are the other Parties providing?

What is NHSBT receiving?

What are the other Parties receiving?

Who is the research Sponsor?

Who is funding the project?

Are there acceptance criteria from the Yes No Sponsor/Funder? If “Yes” please provide details.

What costs are involved with the project? Could these change at all? (For example, these can be staff, travel, expenses consumables, equipment costs, estates costs, use of institution space, administrative and IT costs.)

Are there payment milestones?

Is there any point at which the project should be Yes No cancelled due to costs? If “Yes” please provide details.

Is there a project Protocol agreed? (Please attach any draft or agreed Protocol.)

For Clinical Trials: Are there periodic meetings and/or oversight committees, and what is the frequency for these meetings?

Are there reporting dates and a final report, and when are these due?

What facilities will be used and by whom?

What equipment will be used?

Who owns, insures and maintains this equipment?

Who is working on this project?

Who employs and appoints them?

Are they essential to the project? Can they be replaced?

Do they require access to NHSBT site(s)/equipment/data/patient(s)/donor(s)?

Will there be subcontracting to third parties?

Are there any suppliers providing equipment or supplies?

What are the delivery or collection requirements for items involved (if applicable)?

Please include any other background information pertinent to the Project.

SUPPORTING DOCUMENTATION

Please confirm supporting documentation provided with this application:

Executed contract(s) already in place for this project Draft contract documentation provided by organisation, submitted for review Finance Schedule(s) approved by Finance Business Partner Variation to Contract Form Protocol (draft/final) Ethics Approval (if applicable) Other (please state)

SECTION C – FINANCE IMPLICATIONS Date reviewed and approved by Finance Business Partner:

If applicable, has the finance schedule been approved by R&D SMT or R&D Committee? Yes No

Please confirm the Contracting Party has undergone required NHSBT credit control check by Accounts Receivable: Yes No (If no, please arrange to do so.)

Estimated financial impact for NHSBT: £ Income Expenditure Not applicable

Total Project value: £

Has a price quotation been made to the customer? Yes No If yes, by whom and when:

Will the price be based on the published NHSBT annual price list? Yes No

If no, please provide further details as to how the price has been generated and the invoicing schedule to be included within the contract:

Cross-Referenced in Primary Document: MPD1284 Page 4 of 4