Incoming Equipment Loan Agreement Form

1. BU Contact Information:

BU Principal Investigator (PI) Name:*

BU PI Department:*

BU PI Phone:*

BU PI Email:*

BU PI Lab Location*

(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 Contact Name:*

Alternate BU Contact Email:*

2. External Party Equipment Provider

External Party Organization Name*

External Party Provider Primary Contact*

External Party Phone:*

External Party Email:*

3. Identification and Description of the Equipment being received by BU:*

4. Description of Research to be conducted at BU with the loaned equipment*

5. What is the approximate value of the Equipment?*

Under $5,000
$5,000 or greater
Don't know

6. Is your research with the requested Equipment being conducted in a BU-owned space?*

If in BMC-owned space, this Equipment Loan Agreement request should be sent to the BMC Grants Office.

Yes
No

BU location of where Research using Equipment will be conducted:

Street Address Address Line 2 City State ZIP Code

7. Will you be using the Equipment on live animals?*

Yes
No

8. Is the Equipment to be used on living persons? If YES, research may not be permitted under an Equipment Agreement alone.*

Yes
No

9. Has the use of the Equipment been submitted to the BU IRB?*

Yes
No
N/A

10. Will you be modifying the Equipment?*

Yes
No

11. Will the Equipment be used in any research project that is funded by industry sponsor(s) other than the Provider of the Equipment?*

Yes
No

12. Do you have funding to support this research?*

Please provide grant/award number, if applicable.

Yes
No

a) Type of Funding:*

Government
Start-up/Discretionary (Internal)

b) Award #:*

c) Title:*

d) Sponsor:*

13. Will any training be required for the operation of the Equipment?*

Yes
No

14. What type of maintenance from the Provider do you expect to receive, if any, for the Equipment?*

15. Will the Equipment be used in conjunction with other materials obtained under other agreements with parties other than the Provider?*

Yes
No

16. Is the Equipment otherwise commercially available for purchase?*

Yes
No

17. Do you anticipate RECEIVING any Confidential Information as a part of this Equipment loan?*

Yes
No

18. Do you anticipate SENDING any Confidential Information as a part of this Equipment loan?*

Yes
No

19. Under this Equipment Loan Agreement, do you anticipate that any inventions will be developed by you from the use of the loaned Equipment?*

Yes
No
I don't know

20. Do you plan to publish the results of the research using the loaned Equipment?*

Yes
No
I don't know

21. Does the sponsor indicate that any of the following restrictions or limitations will be applied to your activities using the Equipment under this agreement? Please check all that apply.*

Not Applicable
Prior approval for dissemination/publications
Restrictions on access or participation by foreign nationals
Export control restrictions [International Traffic Arms Regulations (ITAR), Export Administration Regulations (EAR), Nuclear Regulations]
I don't know

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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Incoming Equipment Loan Agreement Form