Internal Submission Form for the Review of Outgoing Material Transfer Agreement (Mta)

UNIVERSITY OF PITTSBURGH OFFICE OF RESEARCH (OR) INTERNAL SUBMISSION FORM FOR THE REVIEW OF OUTGOING MATERIAL TRANSFER AGREEMENT (MTA)

FOR UNIVERSITY REVIEW AND SIGNATURE, SUBMIT THE FOLLOWING MATERIALS BY EMAIL TO ( [email protected] ) **COMPLETED SUBMISSION FORM AND ANY COMPLIANCE DOCUMENTATION AS REQUESTED BELOW Basic Information 1. Principal Investigator: 2. Department Administratively Department Name: Responsible for this Agreement: Department ID: 4. Title of Submission: 5. Department Administrative Contact for PI Name:

Contracting Party Information1 1 Contracting Party Name: 2. Legal Contact Name: 3. Legal Contact E-Mail Address: 4. Legal Contact Phone Number: 5. Scientific Contact Name: 6. Scientific Contact E-mail: 7. Does the Principal Investigator have a Yes financial relationship with any of the Contracting Parties listed above that No is or should be disclosed on your University of Pittsburgh Conflict of Interest disclosure form? If Yes, please explain:

Material Information 1. Identify all materials being shared under this MTA: 2. Do these contain biological material? Yes

Material Source Information

1. Was all material independently Yes developed by you or under your direction at Pitt? No

If no, please explain: 2. Does the material incorporate or is Yes the material derived from materials obtained from a No Third party? If Yes, please explain:

3. Was any of the material brought to Yes Pitt from somewhere else? No

If Yes, please explain:

1 If there are multiple contracting parties for this agreement, please attach a list (including legal contact information) to your submission package.

Form Revision Date: 9/2014 Page 1 INTERNAL SUBMISSION FORM FOR THE REVIEW OF OUTGOING MATERIAL TRANSFER AGREEMENT (MTA) 4. Are there alternative sources to Yes provide the material? No

Form Revision Date: 9/2014 Page 2 INTERNAL SUBMISSION FORM FOR THE REVIEW OF OUTGOING MATERIAL TRANSFER AGREEMENT (MTA) 5. Is the material under disclosure to or Yes patented by Pitt Office of Technology Management No (OTM)? OTM Staff Member: OTM Case Number: 6. Are there any other Yes agreements/funding/materials applicable to your research (List all No that apply, i.e., Sponsored Research Agreement, Government or Other Grant, CDA, License, If Yes, please provide the Institution or Project Number(s): MTA, Subcontract, Other Agreement)? Material Recipient Information

1. Do you require reimbursement for the Yes cost to provide the material? No

If Yes, please explain: 2. Do you require the recipient to Yes collaborate, share results or anticipate that they will jointly No publish with you? If Yes, please explain:

3. Attach the recipient's Scope of Work Recipient SOW: describing their use of the material as approved by Pitt PI or enter it here: Export Control Information

1. Do you have any reason to believe that Yes the Material to be shipped may support: (1) the No design, development, production, stockpiling or use of a nuclear If Yes, please explain: explosive device, chemical or biological weapons, rockets/missiles, or space launch vehicles OR (2) a Chinese military end-use OR (3) an illegal activity? 2. Do you have knowledge that the item Yes or information will be used on a foreign vessel or No aircraft? If Yes, please explain:

3. Does the Material have any military, Yes intelligence or nuclear applications? No

Form Revision Date: 9/2014 Page 3 INTERNAL SUBMISSION FORM FOR THE REVIEW OF OUTGOING MATERIAL TRANSFER AGREEMENT (MTA) 4. Has anyone informed you that the Yes Material is export-controlled under the US export control No regulations? If Yes, please explain:

Form Revision Date: 9/2014 Page 4 INTERNAL SUBMISSION FORM FOR THE REVIEW OF OUTGOING MATERIAL TRANSFER AGREEMENT (MTA) 5. Is the Material a chemical or biological Yes agent as set forth in the Australia Group Common Controls List No (http://www.australiagroup.net/en/contr ollists.html)? If Yes, please explain:

6. Is the Material a toxicological agent Yes listed in the Matrix - ITAR toxicological agents? No (http://www.research.pitt.edu/sites/defa ult/files/u21/Matrix%20-%20ITAR If Yes, please explain: %20Toxicological%20agents.pdf) 7. Are you shipping the Material to a Yes location outside the United States or to a foreign entity within the United No States? If Yes, please provide: Address: Country: Compliance Information 1 What is the origin of these materials? Human

Animal

Plasmid

Other or Unknown

If Other of Unknown, explain:

Human Origin Information ( Not Applicable)

1. IRB Approval 2. Is the Material taken from a decedent (cadaver)?

3. Does the material contain human stem cells?

Animal Origin Information ( Not Applicable)

1. Is the material a live animal? Yes

Form Revision Date: 9/2014 Page 5 INTERNAL SUBMISSION FORM FOR THE REVIEW OF OUTGOING MATERIAL TRANSFER AGREEMENT (MTA) No

If Yes, please attach IACUC letter of approval.

Form Revision Date: 9/2014 Page 6 INTERNAL SUBMISSION FORM FOR THE REVIEW OF OUTGOING MATERIAL TRANSFER AGREEMENT (MTA) Other Compliance Information 1. Does the material or research with the Yes material involve recombinant or synthetic nucleic acid molecules? No

Is IBC Approval pending? Yes No If no, please attach approval letter. 2. Does the material require Radiation Yes Safety Office approval? No

Is Radiation Safety Office Approval pending? Yes No If no, please attach approval letter. 3. Is the material on the Federal Select Yes Agent list? http://www.selectagents.gov/ No

Is EH & Safety Approval pending? Yes No If no, please attach approval letter. Additional Information

1. Additional information relevant to the review of this request, including any time constraints:

SUBMIT THE REQUESTED MATERIALS BY EMAIL TO [email protected]

ALL FIELDS ON THIS FORM ARE REQUIRED.

FORMS MISSING INFORMATION OR SUBMISSION PACKAGES THAT DO NOT INCLUDE REQUESTED DOCUMENTATION WILL BE RETURNED TO THE SUBMITTER.

Form Revision Date: 9/2014 Page 7