INCOMING MATERIALS QUESTIONNAIRE
FOR UTHSCSA INVESTIGATOR TO COMPLETE
This information will be used to review the terms of the MTA for compliance with UTHSCSA policy,
federal and state laws, and to avoid conflicts with any third parties. Please do not sign the agreement
as it needs to be reviewed first.
To expedite processing of the MTA, please email a Word version of the agreement and contact
information for the other party along with this form to contracts@uthscsa.edu in OSP.
Date:
Principal Investigator’s Name:
Provider’s Name:
Provider’s Institution:
Material(s) Requested:
Brief description of the research using the requested material(s):
1) What is the source of funds for this project using the incoming material(s)?
NIH:
Foundation:
Departmental or Start-up funds:
Project ID#
2) Will you use the incoming material(s) named above with any other material(s) provided by an
organization or colleague outside UTHSCSA?
Yes
No
 Other materials may include: cell lines, plasmids, drugs, compounds, human materials, GFP or
other reagents and/or animals, see #9 below.
Name of other material(s)
Strain or catalog number(s)
Obtained from
Purchased
No
Are there any MTAs or licenses for the other material(s)?
If Yes, please attach a copy for OSP.
Yes
Yes
No
Biological repositories may have online MTAs, special terms of use online or require registration
forms that control use and transfer of other materials in this project.
 ATCC established a Master MTA with UTHSCSA that controls use and transfer of their cell
lines as designated by their depositors. You acknowledge these terms by ordering from
ATCC. A separate MTA or license may be required by ATCC and their depositors.
 Some commercial reagent providers send limited use licenses with the material(s) as a
package insert or lists them on the company website. These licenses control the use and
transfer of these material(s) like a MTA upon purchase of the material(s).
3) Will you be using the incoming material(s) with any transgenic animal(s) expressing a recombinant
activated oncogene?
Yes
No
If Yes, a license may be required from DuPont.
4) Could the use of the incoming material(s) result in a finding that may be of commercial value?
Yes
No
4a) if yes, how do you anticipate it will be of commercial value?
5) Will any invention, previously disclosed to UTHSCSA’s Technology Office of Transfer and
Commercialization (OTTC), be used in this research project with the incoming material(s)?
Yes
No
OTTC file number?
Has a patent application been filed? #
Yes
No
6) Is/are the incoming material(s) commercially available from another source(s)?
Yes
No
Yes
No
If Yes, name of other source(s)
7) Will you be adding to or changing the incoming material(s) in any way?
Will you be creating derivatives incorporating the incoming material(s) into other material(s)? See #2
for other materials.
Yes
No
Please describe
8) Have you received IACUC approval for use of these materials?
Not required for invertebrates.
Yes
No
N/A
9) Will you be breeding the incoming animals for this research project?
Are any of the animals being used transgenic?
Will transgenic progeny develop cancer?
a) Breeding for identical progeny?
b) Breeding for cross-bred progeny?
What is the source of the other animal(s) being cross-bred?
Yes
No
Yes
Yes
Yes
Yes
N/A
No
No
No
No
What is the name/catalog number of the strain?
Has a MTA been completed for animals to be cross-bred with the requested incoming animals?
Yes
No
If Yes, attach a copy of the MTA for OSP.
 The Jackson Laboratory has restrictions on use of animals on their webpage for each strain
as determined by their depositors in place of a MTA. Certain uses may require special
permission or a license from the depositor.
10) Are these materials on the CDC or APHIS list of select agents?
Yes
No
See www.cdc.gov/od/sap/docs/salist.pdf for a list of select agents and toxins.
11) Are there any special bio-safety requirements or does by Environmental Health & Safety Office need
to give approval for the requested material?
Yes
No
12) Are these materials of human origin?
No
If yes, are they de-identified of any personally identifiable patient information?
If not, please attach your IRB approval letter or exception number for OSP.
Yes
Yes
No