Appendix B
Instructions for sending Human Tissue to an Institution for Research Purposes
You should use this form where Human Tissue is to be transferred from Sussex to an academic or research institution for
research purposes. This form should not be used for the purpose of sending Human Tissue to a service provider for diagnostic or
testing purposes.
1. QUESTIONNAIRE
SUSSEX’ PRINCIPAL INVESTIGATOR DETAILS
Name
Office
Address
Telephone
No.
School
Email
RECIPIENT INSTITUTION DETAILS
Name of Recipient Institution
Name of School/Department
Address of Recipient Institution
Name of Contact at Recipient
Institution
Email for
Contact
CHECKLIST
1.
Is the Recipient Institution Licensed by the
Human Tissue Authority?
2.
If the answer to item 1 is “Yes”, please
provide the Recipient Institution’s Human
Tissue Authority Licence No.
3.
Is the transfer of the Materials to the
Recipient Institution covered by ethical
approval given either to the Recipient or to
Sussex by a research ethics committee
which, within the UK, is recognised under the
Human Tissue Act 2004?
If “Yes”, please attach a copy of the letter of
approval.
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Appendix B
THE MATERIALS
4.
Description of Materials to be Transferred
(please be as detailed as possible)
5.
Quantity of Materials to be Supplied
6.
Is there or will there be “appropriate
consent” from each Donor, as required by
the Human Tissue Act 2004, which permits
the use of the Materials in the Recipient
Institution’s research?
7.
If the Materials have been or will be obtained
by Sussex from Human Subjects, please
provide a copy of the ethical approval under
which the Materials have been or will be
obtained and tick the box on this row in the
column opposite.
8.
Were the Materials obtained by Sussex from
a third party?
9.
If you have answered “Yes” to item 8, please
provide the name of the third party and
provide a copy of the MTA and/or other
document(s)
(e.g.
NDA,
research
collaboration agreement) under which the
Materials were obtained.
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11.
If “No”, please explain why consent is not required
Copy of the letter or certificate of ethical approval
attached
Name of third party who supplied the Materials to Sussex:
(Please attach copy of MTA or other document under
which the Materials were obtained).
If you have answered “Yes” to item 8, please
provide a copy of the ethical approval under
which the Materials have been or will be
obtained and tick the box on this row in the
column opposite.
Were the Materials obtained by Sussex using
funding from a third party?
A copy of the relevant ethical approval is attached
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12.
Appendix B
If you have answered “Yes” to item 11,
please provide the name of the third party
whose funding was used to obtain the
Materials and Sussex’s research project
code for the relevant project or other
information sufficient to identify the project.
13.
Are the materials known to be toxic,
infectious or in any other way dangerous?
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What conditions of storage will apply to the
Materials?
USE OF THE MATERIALS BY RECIPIENT INSTITUTION
15.
What will the Recipient Institution do with
the Materials? (please give a description of the
research which the Recipient Scientist may carry out using
the Materials – this will go into the MTA. Please also attach
any protocol or outline of the research)
16.
What results will be, or are likely to be
generated from the Recipient Institution’s
use of the Materials?
In your opinion, how likely is it that the
Recipient Institution’s research using the
Materials will generate any invention, or
other result that might have commercial
value or be used in future research which
will have commercial value?
Extremely unlikely
Unlikely
Possible
Difficult to say
17.
For how long will the Recipient Institution
need to retain the Materials?
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18.
Appendix B
When the Recipient Institution has finished
using the Materials, should they destroy any
remaining Materials and any data provided
with them or return Materials and data to t
Sussex?
2. DECLARATION BY THE PINCIPAL INVESTIGATOR
I have checked and satisfied myself that the transfer of these Materials is permitted by the consent given by the
Donor and that there is no other reason to the best of my knowledge why the transfer to the Recipient Institution
should not be made.
Signed by the Principal Investigator
Date of signature__________________________________________
Please email a scan of this form, with an electronic copy of the research summary or protocol (if applicable) and
other documents required to Contracts.Instructions@sussex.ac.uk or send a hard copy of all documents to Contracts
& IP, 2nd Floor, Falmer House, marked as “MTA Request”. The Contracts Team will then, provided it is satisfied with
the information you have provided, prepare an outgoing MTA in Sussex’s standard form and send this to you for
forwarding to the Recipient Institution. The matter will be allocated to a member of the Contracts Team who will
contact you if further information is required by the Contracts Team and this will also be the person to whom you
refer any questions or concerns that may be raised by the Recipient Institution.
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