U N I V E R S I T Y O F P I T T SB U R G H O F F I C E O F R E S E A R C H ( O R )
Y
Y
O U T G O I N G M A T E R I A L T R AN S F E R A G R E E M E N T ( M T A )
1.
2.
4.
Principal Investigator:
Department/Institute/Center that will be administratively responsible for this Agreement:
Title of Submission:
5. Department Administrative Contact for PI Name:
Department/Institute/Center Name:
Department/Institute/Center ID:
1
2.
3.
4.
5.
Contracting Party Name:
Legal Contact Name:
Legal Contact E-Mail Address:
Legal Contact Phone Number:
Scientific Contact Name:
6.
7.
Scientific Contact E-mail:
Does the Principal Investigator have a financial relationship with any of the
Contracting Parties listed above that is or should be disclosed on your
University of Pittsburgh Conflict of
Interest disclosure form?
Yes
No
If Yes, please explain:
1.
2.
Identify all materials being shared under this MTA:
Do these contain biological material?
3. Is the material commercially available?
Yes
No
Yes
No
1.
2.
3.
4.
Was all material independently developed by you or under your direction at Pitt?
Does the material incorporate or is the material derived from materials obtained from a
Third party?
Was any of the material brought to
Pitt from somewhere else?
Are there alternative sources to provide the material?
Yes
No
If no, please explain:
Yes
No
If Yes, please explain:
Yes
No
If Yes, please explain:
Yes
No
If Yes, please explain:
Form Revision Date 3/15/15
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INT ER NA L S UB MISSIO N F O RM F O R T H E R E V I E W O F O U T G O I N G M A T E R I A L T R A N S F E R A G R E E M E N T ( M T A )
5.
6.
Is the material under disclosure to or patented by Pitt Office of Technology
Management
(OTM)?
Are there any other agreements/funding/materials applicable to your research (List all that apply, i.e., Sponsored Research
Agreement, Government or Other
Grant, CDA, License,
MTA, Subcontract, Other
Agreement)?
Yes
No
OTM Staff Member:
OTM Case Number:
Yes
No
If Yes, please provide the Institution or Project Number(s):
1.
2.
3.
Do you require reimbursement for the cost to provide the material?
Do you require the recipient to collaborate, share results or anticipate that they will jointly publish with you?
Attach the recipient's Scope of Work describing their use of the material as approved by
Pitt PI or enter it here:
Yes
No
If Yes, please explain:
Yes
No
If Yes, please explain:
Recipient SOW:
1. Do you have any reason to believe that the Material to be shipped may support: (1) the design, development, production, stockpiling or use of a nuclear explosive device, chemical or biological weapons, rockets/missiles, or space launch vehicles OR (2) a Chinese military end-use OR (3) an illegal activity?
Yes
No
If Yes, please explain:
2. Do you have knowledge that the item or information will be used on a foreign vessel or aircraft?
3. Does the Material have any military, intelligence or nuclear applications?
4. Has anyone informed you that the
Material is export-controlled under the
US export control regulations?
Yes
No
If Yes, please explain:
Yes
No
If Yes, please explain:
Yes
No
If Yes, please explain:
Form Revision Date: 3/15/15
Page 2

INT ER NA L S UB MISSIO N F O RM F O R T H E R E V I E W O F O U T G O I N G M A T E R I A L T R A N S F E R A G R E E M E N T ( M T A )
5. Is the Material a chemical or biological agent as set forth in the Australia
Group Common Controls List
( http://www.australiagroup.net/en/contr ollists.html
)?
6. Is the Material a toxicological agent listed in the Matrix - ITAR toxicological agents?
( http://www.research.pitt.edu/sites/defa ult/files/u21/Matrix%20-
%20ITAR%20Toxicological%20agents.
pdf )
7. Are you shipping the Material to a location outside the United States or to a foreign entity within the United
States?
Yes
No
If Yes, please explain:
Yes
No
If Yes, please explain:
Yes
No
If Yes, please provide:
Address:
Country:
1 What is the origin of these materials? Human
Animal
Plasmid
Other or Unknown
If Other of Unknown, explain:
1. Was the material taken from a living individual?
2. Is the Material taken from a decedent
(cadaver)?
Yes
No
If Yes, please attach the Pitt IRB letter of approval.
Yes
No
If Yes, please attach CORID letter of approval.
3. Does the material contain human stem cells?
Yes
No
If Yes, please attach hSCRO letter of approval.
Are the human embryonic stem cells on the NIH stem cell registry? Yes No
1. Is the material a live animal? Yes
No
If Yes, please attach IACUC letter of approval.
Form Revision Date: 3/15/15
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INT ER NA L S UB MISSIO N F O RM F O R T H E R E V I E W O F O U T G O I N G M A T E R I A L T R A N S F E R A G R E E M E N T ( M T A )
1. Does the material or research with the material involve recombinant or synthetic nucleic acid molecules?
2. Does the material require Radiation
Safety Office approval?
3. Is the material on the Federal Select
Agent list? http://www.selectagents.gov/
Yes
No
Is IBC Approval pending? Yes No
If no, please attach approval letter.
Yes
No
Is Radiation Safety Office Approval pending? Yes No
If no, please attach approval letter.
Yes
No
Is EH & Safety Approval pending? Yes No
If no, please attach approval letter.
1. Additional information relevant to the review of this request, including any time constraints:
DO NO T EM AIL TH I S F O RM .
IT IS A N E X AMPLE OF M Y RA S UBM ISS IO N QU EST IONS -
Form Revision Date: 3/15/15
Page 4