Material Transfer Agreement (MTA) Request: Outgoing MTAs

Outgoing Material Transfer Agreement

BU encourages researchers to exchange non-hazardous or non-human research materials for nonprofit, basic research purposes without a formal legal agreement, when practicable. If you are unsure whether an MTA is needed, please review the information under Outgoing Material Transfer Agreements at Material Transfer Agreements.

NOTE:If you are looking to deposit plasmids to Addgene, instead of submitting this form, please go to Addgene: Start Plasmid Deposit and follow the Addgene deposit process. During this process, Addgene will send you a questionnaire for you to provide the relevant information needed to complete the diligence for your deposit. A copy of your answers to this questionnaire will be sent to OTD along with the details of the deposit request.

1. BU/BMC Contact Information:

BU/BMC Principal Investigator (PI) Name:*

BU/BMC PI Department:*

BU/BMC PI Phone:*

BU/BMC PI Email:*

BU/BMC PI Lab Location*

(Include room, street, and ZIP code.)

Check here if any/all of BU/BMC development of the MATERIAL was done in another lab than the Lab Location above.

Check here if any/all of BU/BMC development of the MATERIAL was done in another lab than the Lab Location above.

BU/BMC location of where MATERIAL was developed/produced:*

(Include room, street, and ZIP code.)

Check here if to specify an alternate BU/BMC contact besides the PI.

Check here if to specify an alternate BU/BMC contact besides the PI.

Alternate BU/BMC Contact Name:*

Alternate BU/BMC Contact Email:*

2. External Party (RECIPIENT) who will be participating in the exchange of the Materials:

RECIPIENT Institution Name:*

RECIPIENT PI:*

RECIPIENT PI Phone:*

RECIPIENT PI Email:*

RECIPIENT Administrative Contact:

RECIPIENT Administrative Contact Phone:

RECIPIENT Administrative Contact Email:

3) Description of the Material being sent by BU/BMC:*

4) Description of Research to be conducted by Recipient with the Material:*

5) Is the RECIPIENT located outside of the U.S.?*

Yes
No

Export Information Checklist *

Export control laws are federal regulations that define the conditions under whichcertain information, technologies, software, and commodities can be transmitted to foreign corporations, organizations or individuals overseas (including U.S. citizens). If you are providing information overseas, the information (or the medium on which it is transmitted) may be subject to federal regulation. Before answering these questions, you should review the University’s Export Control web site. Please complete the following Export information checklist. If you are UNABLE to confirm any of these statements or have any questions, contact the Export Control Director at export@bu.edu.

I have confirmed that the MATERIAL is not designed or adapted for a military or space application and does not relate to and will not be used in connection with weapons of mass destruction, nuclear activities and research, space launch vehicles, unmanned air vehicles, or maritime nuclear propulsion.*

Yes
No

I have confirmed that NO “red flags” from the Department of Commerce’s Bureau of Industry and Security (BIS) Red Flag Indicator list are present.*

Bureau of Industry and Security (BIS) Red Flag Indicator list

Yes
No

I have confirmed that the information or material to be transferred does not appear on the Commerce Control List (CCL)*

Commerce Control List

Yes
No

I have confirmed that the information or material to be transferred does not appear on the U.S. Munitions List.*

U.S. Munitions List
(You should review both the CCL and the Munitions List online if the material you plan to transfer fits within one of the categories. If the information/technology, materials/software that you plan to transfer are on any of these lists, contact the University Export Control Director export@bu.edu to help you determine whether an export license is required for this transfer.)

Yes
No

6) Will you charge the RECIPIENT a fee for the transfer?*

Yes
No

a. Preparation/Distribution Costs:*

Transfer of materials to Universities and Nonprofits are normally provided at no cost, however, you may request a fee solely to reimburse preparation and distribution costs of the Material. For transfers to a commercial/industry Recipient, you may charge additional amounts. Please specify costs/fees below and OTD will contact you to explore possible options.

b. Additional charges, if any (commercial only):

7) Will you be sending live animals as part of this transfer?*

Yes
No

a. Strain Name:*

b. Name and function of gene:*

c. Intended Use:*

By checking this box, I acknowledge that I must submit an Export Request to the BUMC Laboratory Animal Science Center or CRC Laboratory Animal Care Facility as applicable. (help)

d. Has this use been approved by the Institutional Animal Care and Use Committee (IACUC)?*

Institutional Animal Care and Use Committee (IACUC)

Yes
No

8) Does the material contain or is it derived from human tissue or specimens OR is the material related to research regulated by an Institutional Review Board (IRB)?*

(Please review the applicable IRB policy (BUMC and/or CRC) before answering this question)

Yes
No

a) Please identify which IRB controls, and provide your IRB protocol number.*

BUMCBoston University Medical Campus
CRCCharles River Campus

IRB Protocol Number*

b) IRB Documentation

Please upload applicable IRB documents e.g., BU IRB approval letter)

Drop files here or

Max. file size: 100 MB.

c) Will you provide the Recipient with ANY DATA related to the materials/samples?*

Yes
No

9) Does the MATERIAL include any of the following?*

(Check all that apply)

a) Material and/or agents developed or stored in the National Emerging Infectious Diseases Laboratory (NEIDL)
b) hazardous material per the Institutional BioSafety Committee (IBC) or Dept. of Transportation (DoT)
c) dangerous goods per the International Air Transport Association (IATA)
d) novel chemical molecule not yet classified under the Toxic Substances Control Act
e) compounds from the BU Center for Molecular Discovery (CMD)
f) materials from the Framingham Heart Study
g) None of the above

10) Was the material developed outside your lab at BU/BMC (even partially), or does it incorporate or derive from third party material?*

Yes
No

a) Please provide (i) the name of third party or where material was developed, (ii) the third party material, and (iii) how it was used to derive the Material.)*

b. Please describe any agreements that apply (MTA-in, SRA, CDA, PO, etc.) and attach files below if available.*

c. Please attach copies of the third party agreements if available:

Max. file size: 100 MB.

11) Is the material related to a current or planned invention disclosure (TDF) filed with OTD?

Yes
No

a. BU/BMC case #, or Patent #*

Principal Investigator Certification:

I certify that the information I have provided about this project is accurate. Furthermore, I certify that I will direct this project in compliance with BU/BMC policies, with the terms and conditions of the resulting MTA, and with all applicable laws and regulations.

Signature:*

You may sign this form using S-signature format e.g., /John Q. Doe/

Date*

Upload any relevant documentation (e.g., draft agreement from external party, IRB approval letter, emails regarding MATERIAL or RECIPIENT, etc.) here:

Drop files here or

Accepted file types: msg, txt, pdf, doc, docx, xls, xlsx, Max. file size: 100 MB.

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