UC Irvine Office of Technology Alliances 5141 California Avenue, Suite 200, Irvine, CA 92697-7700 Tel: (949) 824-2683; Fax: (949) 824-3880 Email inquiries to: [email protected] Incoming Material Transfer Request Form This document is for internal use only – please do not provide it to outside organizations. UCI Investigator: Department: Telephone: Fax: Email: Primary Contact, other than UCI Investigator Name & Title: Telephone: Fax: Email: Outside Organization: Scientist Contact: Telephone: Fax: Email: MTA Negotiator of Outside Organization Name & Title: Telephone: Fax: Email: 1. Date the Material(s) will be needed: ____/_____/______ 2. Dates of the research period using Material(s): ____/_____/______ to ____/_____/______ 3. Describe the Material(s) to be transferred, including if of human or animal origin: IRB Compliance: 4. Will your research use human subjects – a living individual about whom an investigator conducting research obtains data through intervention or interaction with the individual? yes no 5. Will your research use identifiable, private information about living individuals? yes no 6. Is your research designed to test the efficacy of a medical device (i.e. in vitro diagnostic device)? yes no If you answered yes to any of Questions #4-6, attach the appropriate IRB approval letter. If you do not have an IRB approval letter, please contact your IRB administrator to obtain IRB approval for your project with the Materials. Once you receive your IRB approval letter, please submit it to the person working with you on this MTA. 7. Are the Material(s) pluripotent human stem cells (adult, embryonic, fetal, iPS, etc.)? 8. Are the Material(s) being used with the intent to derive pluripotent human stem cells? yes yes no no If you answered yes to either Question #7 or Question #8, attach the appropriate hSCRO approval letter. If you do not have an hSCRO approval letter, please contact Cathryn Lucas at [email protected] to obtain hSCRO approval for your stem cell related work. Once you receive your hSCRO approval letter, please submit it to the person working with you on this MTA. General: 9. Are the Material(s) on the Federal Select Agent list? See list at http://www.selectagents.gov/ yes no 10. What is the Source of Funding (current or anticipated) supporting your research with requested Material(s) (e.g., NIH- non-profit or industry sponsor); Include the name of sponsor/funding agency and award number if any: 11. Are the Material(s) necessary in order to complete the research funded by the sponsor/funding agency listed above? yes no 12. Describe in 2 or 3 sentences your research plans using the Material(s) including whether you will make derivatives or modifications of the Material(s). 13. The proposed transfer represents: formal research collaboration or transfer of Material(s) 14. Do you plan to use third party materials that were brought into UCI under a different MTA in your research with the Material(s)? yes no not sure If yes, identify other material(s) and their provider(s): 15. Can the Material(s) be purchased from the providing organization or obtained from another source? yes no not sure 16. Do you have a financial interest in the outside institution providing the Material(s) (income, consulting, gift, stock ownership, sponsored/reimbursed travel or management position)? yes no 17. Was the decision to undertake this research based on receiving access to the Material(s) by the organization providing the requested Material(s)? yes no 18. Will the materials be provided to UCI at no cost other than shipping fees? yes no 19. Please list collaborators on this project if any: 20. Any additional information that would be useful, please provide it here: PI Signature: _________________________________ Date: __________________________________ If PI submits this document via email, PI’s signature is not required. Instructions for Incoming Material Transfer Request Form Instructions for completing the Incoming Material Transfer Request Form: Questions 4-6: If you are conducting “human subjects” research, please provide your IRB approval or exemption letter. Visit http://www.research.uci.edu/ora/hrpp/index.htm for additional information about the IRB. Questions 7&8: hSCRO approval must be obtained prior to the MTA being signed. For information and forms, visit http://www.research.uci.edu/ora/hscro/index.htm. Question 9: Please visit http://www.ehs.uci.edu/programs/biosafety/ibc/index.html for additional information on UCI’s Select Agents Program and how to obtain authorization to use select agents. Questions 10 & 11: Source of Funding is needed to determine if there are any conflicts between MTA language and funding source (such as IP, licensing obligations, etc.). If the funding source already has certain licensing or other obligations, UCI cannot agree to conflicting terms in the MTA. Question 12: The Scope of Work provided should be the specific research to be performed with the requested Materials. This Scope will tie in with the authorized use of the requested Materials, the definition of inventions made with the Materials, and the licensing rights to such inventions, etc. Also, some MTAs place restrictions on creating modifications or derivatives of the requested Materials. Question 13: If there will be any unfunded collaborative research between UCI and the Provider, it is important to set out the rights to ownership of any creations or inventions resulting from the research. Question 14: Many MTAs place restrictions on research involving other Materials resulting in obligations to another third party. It is important to abide by the terms of any existing agreements and to make sure the MTA language will not conflict with existing obligations. Question 15: This is used in assessing whether the Material is proprietary and helps in determining if restrictions in the agreement are reasonable. It is also good to know if there are options other than the Provider for obtaining the Material should that be a better choice. Questions 16-18: For MTAs with for-profit or certain non-profit entities, UCI needs to check for any potential conflicts of interest for the UCI Investigator. Question 19: Collaborators requiring access to the Material may require a separate MTA with the Provider.