Office Use Only:
Assign Number ______________
Protocol Verification ________ _
Database __________________
Office of Research Development
MATERIAL TRANSFER AGREEMENT (MTA) CHECKLIST
To be completed and submitted electronically to Sandy Rhoades with any MTAs or other restrictions attached
UT Principal Investigator
Telephone Number
Date
MATERIAL TO BE TRANSFERRED:
Detailed description of material(s) being transferred (name, formula, strain/quantity/gender, Etc.):
Is the material to be transferred genetic material, biohazardous material, or a select agent/toxin?
NO
YES
http://www.utoledo.edu/policies/academic/research/pdfs/3364-70-06.pdf
If YES, what is the appropriate biosafety containment level for the agent? BSL-1/ABSL-1
Please provide approved IBC#:
BSL-2/ABSL-2
BSL-3/ABSL-3
If pending, provide the date of submission of protocol
https://www.utoledo.edu/depts/safety/docs/lab_safety/IBC.pdf
Is the material to be transferred related to human subjects research? NO
YES
https://www.utoledo.edu/research/RC/HumanSubs/
If YES, please provide IRB#:
If pending, provide the date of submission of protocol
Material(s) collected according to 45 CFR Part 46, “Protection of Human Subjects?” NO
YES
Is the material to be transferred cadaveric tissue?
NO
If YES, provide UT-CRC #:
Are animals being transferred?
NO
YES
https://www.utoledo.edu/graduate/files/UTCadaverRes_Appl_V4_091707.pdf
If pending, provide the date of submission of protocol
YES
If YES, provide IACUC#:
https://www.utoledo.edu/research/RC/animal/ProtocolProcedure.html
If pending, provide the date of submission of protocol
Will Material be used for a Commercial Purpose? NO
YES
Detailed description of Research Purpose:
DATE NEEDED:
INCOMING MATERIAL
Material Provider:
Institution/Company:
Providing Scientist:
Administrative Contact Person:
Email Address:
Email Address:
Telephone Number:
List UT account number and source(s) of funding to be used for this research:
Any other material(s) to be used in the same experiment(s) obtained under an MTA or other restrictions?
NO
YES
If YES, list provider(s), material(s), restrictions, and MTA number (if known):
Is material available commercially?
NO
YES
Are you purchasing material?
NO
YES
Note: It is the responsibility of the P.I. to ensure that all regulatory approvals required for the receipt and use of this new Material have been obtained PRIOR to
its issue. This may require amending existing regulatory protocols or submission of new protocols to cover the use of this new Material. Please follow the
university’s procedure for Receipt of Hazardous Materials (HM-08-031). Contact Environmental Health and Radiation Safety at 419.530-3600 for assistance.
OUTGOING MATERIAL
Material Recipient:
Institution/Company:
Receiving Scientist:
Administrative Contact Person:
Email Address:
Email Address:
Telephone Number:
List the name of the institution/company that provided the material to be transferred or indicate if it was created at UT:
If created at UT, list UT account number and source(s) of funding that were used to produce material(s):
Was any part of the material to be transferred obtained under an MTA or any other restrictions(s)?
NO
YES
(e.g. commitments to funding agency, purchase agreement, etc.)
If YES, list commitments, restrictions, and MTA number (if known):
Was anything used to produce the material(s) to be transferred obtained under an MTA or other restriction? NO
YES
If YES, list provider(s), material(s), restrictions, and MTA number (if known):
Note: Any shipment of infectious materials and/or human materials MUST be in accordance with the US federal DOT(49 CFR) and the international (airline)
regulations (IATA). Individuals shipping certain biological, chemical and radioactive materials are required to be trained and certified. Only properly trained
individuals can sign dangerous goods declaration form and accept responsibility for proper shipment. Please follow the university’s procedure for Shipping and
Packaging Hazardous Materials (HM-08-031). Contact Environmental Health and Radiation Safety at 419.530-3600 for assistance.
Updated 11-24-15