MTA human tissue samples
Principal Investigator:
Dept.
Telephone:
e-mail:
Topic of Study:
Study Name:
Helsinki No:
Protocol No: ___________
Recipient of Samples:
Name of Recipient Institution:
Type of Tissue: ______
Quantity:
Study Period:
Source of Funding:
Helsinky (Ethics Committee) Authorization:
Statement:
Recipient warrants and undertakes: (1) it has warranted that it has obtained all necessary
approvals and permits required under law to perform the Study (including with respect to the
usage of the Tissues) and there is no impediment under any law or agreement to execute the
Study. (2)
The Tissues will be used solely for the purposes expressly detailed in the
Protocol and that it will not use the Tissues for any purpose other than expressly defined in the
Protocol and will not conduct any analysis or modification of the Tissues. Particularly, the
Tissues shall not be utilized in, or co-mingled with, any other research projects and/or
programs ongoing now or in the future by the Recipient. (2) Upon the earlier of expiration or
termination of Study Recipient at its own cost and expense shall return or destroy all unused
Tissues. Recipient shall promptly provide Fund with a written confirmation that all Tissues
have been destroyed or returned to Fund, as the case may be. (3) it agrees not to transfer
and/or sell and/or lease and/or directly or indirectly commercialize the Tissues and/or any part
thereof and/or let any third party, directly or indirectly, examine the Tissues and/or the results
of such examination, for whatever purpose Recipient shall allow access to the Tissues only to
such personnel to whom access is necessary for the conduct of Study described in the
Protocol. (4) it shall at all times use the Tissues in a safe manner and shall at all times comply
with all applicable Israeli laws, rules and regulations (including all Israeli Ministry of Health
regulations and/or guidelines) pertaining to the Tissues and the use thereof. (5) Without
derogating from its undertaking not to use and/or examine the Tissues other than within the
scope of the Study and for this purpose only, it is hereby expressed that the Recipient shall not
have any right or interest in the Tissues and/or any part thereof and/or in any of the
information which may be derived from the Tissues other than the information resulting
directly from the conduct of, or within the scope of, the Study. (6) Subject to and without
derogating from Recipient's undertaking under this letter and/or Recipient's undertakings not
to use and/or examine the Tissues other than for performing the Study and for this purpose
only, the Recipient hereby undertakes to keep in absolute confidence, not to transfer to any
person and/or entity and not to make any use any information derived from the Tissues.
Without derogating from Recipient's undertakings under any law and/or the provisions of this
Agreement, the Recipient shall keep and shall procure that its employees and/or any third
party on its behalf keeps in absolute confidentiality the names and identity of the Participants
in the Study (unless the relevant Participant has given its written consent to the Fund in which
event the Fund shall approve such disclosure in writing and in advance), the community they
come from and/or live in and/or their origin, should any such information come into their
possession for whatever reason.
Recipient hereby warrants that it is fully aware that the Tissues may be hazardous and may
cause damage and loss (including personal injury or death) to the Recipient and/or any of its
employees and/or agents and/or any third party on its behalf. Recipient shall be solely
responsible for transferring the Tissues and/or handling the Tissues and shall be responsible
for any damage and/or loss caused to the Recipient and/or and of its employees and/or agents
and/or any third party on its behalf and/or the Fund and/or the TASMCand/or any of its
employees and/or agents and/or any third party on their behalf as a result of handling and/or
using and/or transferring the Tissues and shall indemnify and hold harmless the Fund and/or
the Fund for such damages and/or loss.
Without derogating from its obligation to indemnify and hold harmless pursuant to the above,
Recipient undertakes that during all relevant times, it shall purchase and maintain an
insurance policy which shall be required in order to provide Fund and/or the Fund adequate
coverage and protection. Recipient shall provide the Fund with insurance certificate upon
demand and shall inform Institution of any change or termination thereof.
The Tissues are being made available only to facilitate the purposes set forth in this
Agreement. THE TISSUES ARE BEING SUPPLIED WITH NO WARRANTIES, EXPRESS
OR IMPLIED, AND TRANSFEROR EXPRESSLY DISCLAIMS ANY WARRANTY OF
MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE OR
NONINFRINGEMENT.
Samples will be transferred and used in accordance with current regulations of the Ministry of
Health and/or Fund.
The
Investigators shall co-author publications relating to the this research, as
scientifically and customarily appropriate.
The investigators agree that any right, title and interest in and to an invention resulting from
the Research and any ensuing patents or patent applications generated from the collaboration
between Research Fund and " Recipient Institution"____________ shall vest jointly, in
equal undivided shares, in RESEARCH FUND and ___________ " Recipient
Institution"____________
Signature of Recipient of Samples: ________________
Date: _________________________
Signature and Stamp: _______________________
Signature of Recipient Institution: ________________
Date: _________________________
Signature and Stamp: _______________________
Signature of Principal Investigator (from Fund): ________________
Date: _________________________
Signature and Stamp: _______________________
Signature of THE MEDICAL RESEARCH FUND NEAR THE TEL AVIV SOURASKY
MEDICAL CENTER (FUND): ________________
Date: _________________________
Signature and Stamp: _______________________
Appendix A- Protocol
Appendix B - Budget