Incoming ADDGENE MTA Request 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/BMC Contact Name:*

Alternate BU/BMC Contact Email:*

2. External Party Information

External Party Material Provider: ADDGENE

3. ADDGENE Order Number*

4. Identification and Description of the Material being received by BU:*

Please include title of related research.

5. Description of Research to be conducted at BU with Material:*

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

Yes
No

If in BU-owned space, the MTA should be sent to the BMC Grants Office.

a) BU location where Research using Material will be conducted (if different from lab address):

Street Address City ZIP Code

b) Is this location within the National Emerging Infectious Diseases Laboratory (NEIDL)?*

Yes
No

7. Will you be using the Material in animals?*

Yes
No

Please provide your IACUC protocol number:*

8. Biosafety Information

a) Is the Material biohazardous?*

Yes
No

Biohazardous materials, infectious agents, select agents, human blood, tissues, cells and cell lines, etc.

b) What is the Biosafety Level (BSL) of the Material? (Check all that apply.)*

9. Do you have IBC approval?*

Yes
No
I don't know if I have IBC approval.

Please provide your IBC protocol number:*

10. Will you be modifying the Material?*

Yes
No

11. Will you be creating any progeny from the Material?*

Yes
No

12. How will you fund the research to be conducted with the Material?

Please provide grant/award number, if applicable.

a) Do you have funding to support this research?*

Yes
No

b) Type of Funding*

Government
Start-up/Discretionary (Internal)
Other

c) Award #:*

d) Title:*

e) Sponsor:*

13. Will the Materials be used with other Materials obtained under other MTAs with parties other than Provider?*

Yes
No
I don't know

If yes, please list other parties involved in this research:*

14. Under this MTA, do you anticipate that any inventions will be developed by you from the use of Materials?*

Yes
No

15. Do you plan to publish the results of the research using these Materials?*

Yes
No

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 Boston University policies, with the terms and conditions of Boston University's Material Transfer Agreement with the Provider 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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