THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO (UTHSCSA)
OUTGOING HUMAN SAMPLES INFORMATION REQUEST FORM
The UTHSCSA Office of Sponsored Programs will use this information to prepare a human
biological material transfer agreement document for academic/non-profit organizations requesting
samples of human biological materials from UTHSCSA’s investigators. (This form is NOT the
MTA.) UTHSCSA Provider Scientist: Please complete and sign the first two pages of this
form. Email or fax Page 3 to the intended Recipient. When it is returned to you, forward all
3 pages to OSP Agreement Specialist at contracts@uthscsa.edu.
If UTHSCSA Scientist desires to send any MATERIAL to a for-profit organization, please contact
the Office of Technology Ventures to prepare the MTA.
Providing UTHSCSA Scientist:
Phone: (_____) _____________
Department:
Fax: (_____) _____________
E-mail: ______________________@uthscsa.edu
Bldg./Room #
Grant/Project ID # for this project:
HUMAN BIOLOGICAL MATERIALS REQUESTED (MATERIAL)
PROVIDER IRB APPROVAL: Human tissues or samples must be collected with Provider Institution’s IRB approved
Protocol or exemption. All human Materials must be de-identified by Provider.
Title of IRB approved Protocol
IRB number
Exemption
(Attach copy of IRB approval or exemption letter and letter from Tissue Bank Manager approving transfer.)
Is the Material and any data related to the Material de-identified?
Yes
No
Proposed time period for RECIPIENT’S use and possession of MATERIAL:
Do you want RECIPIENT to return or destroy any remaining MATERIAL, progeny and unmodified derivatives
after completing RESEARCH PLAN?
□ Return □ Destroy
Does the MATERIAL contain a select agent or toxin as defined by the federal government? See
www.cdc.gov/od/sap/docs/salist.pdf for a list of select agents and toxins.
□ No □ Yes
If Yes, please describe
Was the MATERIAL originally obtained from another firm, institution or colleague?
□ No □ Yes If Yes, who was the original provider? If No, where was it developed and by whom?
Has the MATERIAL been disclosed to UTHSCSA’s Office of Technology Ventures as an invention?
□ No □ Yes If Yes, UTHSCSA file number
Is MATERIAL patented or patent pending?
□ No □ Yes □ Not sure
Will RECIPIENT be producing any progeny or unmodified derivatives from MATERIAL?
□ No □ Yes □ Not sure
Has a description of MATERIAL been published?
□ No
06/30/16
□Yes
If Yes, where and when (citation)
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OUTGOING HUMAN SAMPLES INFORMATION REQUEST FORM
Do you want a copy of the research results from RECIPIENT?
□ No □ Yes
Do you want to review RECIPIENT’S findings prior to publication?
□ No □ Yes
Do you want to be acknowledged in RECIPIENT’S publication(s)?
□ No □ Yes
Is the transfer of MATERIAL part of a collaboration?
□ No □ Yes If Yes, do you have a written agreement describing the collaboration?
□
No
If yes, please attach a copy of the agreement.
Likelihood of an invention resulting from RECIPIENT’S use of the MATERIAL?
□ Highly possible
□ Somewhat possible
□ Not expected
Do you wish to be reimbursed by RECIPIENT for the cost of the MATERIAL?
□ No □ Yes If Yes, please provide cost and account number costs were encumbered from
UTHSCSA SCIENTIST:
To the best of my knowledge, the above information is true and correct.
Signature:
06/30/16
Date:
2
□ Yes
THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO (UTHSCSA)
HUMAN SAMPLES INFORMATION REQUEST FORM
The UTHSCSA Office of Sponsored Programs will use this information to prepare a human
biological material transfer agreement document for academic/non-profit organizations requesting
samples of human biological materials from UTHSCSA’s investigators. (This form is NOT the
MTA.)
Please read and complete all the line items on this form, then email or fax it to the Provider
Scientist, who will forward it to UTHSCSA’s Office of Sponsored Programs’ Agreement
Specialist to prepare the Human Biological Material Transfer Agreement.
Providing UTHSCSA Scientist:
Phone: (_____) _____________
Department:
E-mail: ______________________@uthscsa.edu
HUMAN BIOLOGICAL MATERIALS REQUESTED (MATERIAL)
RECIPIENT INSTITUTION
Name of Non-profit Institution requesting MATERIALS (RECIPIENT)
Business Address of Non-profit Institution (RECIPIENT)
Contact person at Recipient Institution who will negotiate the MTA :
Phone: (_____) _____________
E-mail:
Name and title of Recipient Institution’s Authorized Signer:
Recipient Scientist (Principal Investigator): Name
Phone: (_____) _____________
E-mail:
Position title________________
Shipping Address: _______________
(Must be a faculty member of the RECIPIENT INSTITUTION)
Contact person if not Recipient Scientist:
E-mail:
Phone: (_____) _____________
Describe RECIPIENT’S intended use of the MATERIAL (Research plan):
Describe the amount of MATERIAL requested and how it is to be packed and shipped: (e.g., x number of x ml
vials of human serum centrifuged for 15 minutes before shipment and packed in ……ice/no ice) Be as specific a
possible.
RECIPIENT IRB APPROVAL:
Recipient Scientist must have approval or exemption from Recipient Institution’s IRB to receive and use the Materials
Recipient: Title of IRB approved Protocol
IRB number
Exemption
(Attach copy of IRB approval/exemption letter to email.)
Recipient must agree not to seek personally identifiable information related to the Materials.
Is the transfer of MATERIAL part of a collaboration?
□ No □ Yes If Yes, do you have a written agreement describing the collaboration? □ No
What is your contribution to the collaboration?
06/30/16
3
□ Yes