Material Transfer Agreement (MTA) Request: Incoming MTAs

1. BU PI 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.)

(optional) Check here if to specify an alternate BU contact besides the PI.

Alternate BU Contact Name and Email

2. External Party Information:

External Party Material Provider/Institution:*

External Party Provider PI:*

External Party Administrative Contact (if known):

External Party Phone*

External Party Email(s)*

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

Please include the title or a brief description of the related research.

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

5. BU-Owned Spaces:

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

If in BMC-owned space, the MTA should be sent to the BMC Grants Office: https://www.bmc.org/research-operations

Yes
No

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

Yes
No

6. Research Location:

a) Will Research conducted using Material occur at a different location than lab address?*

Yes
No

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

(Include room, street, and ZIP code.)

7. Animal Information:

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

Yes
No

Please provide your IACUC protocol number:*

b. Will you be receiving live animals as a part of this transfer?*

Yes
No

Please provide your IACUC protocol number:*

8. Is the Material to be used in living persons? If YES, research is not permitted under MTAs.*

Yes
No

If you intend to use the material in humans, we will reach out to you to discuss this MTA further.

9. Human-Derived Material:

a) Is this Material derived from humans?*

Yes
No

b) Has the use of this Material been submitted to the BU IRB?*

Yes
No
N/A

10. Biohazard and Biosafety Information:

a) Is the Material biohazardous?*

E.g. Biohazardous materials, infectious agents, select agents, human blood, tissues, cells & cell lines, etc.

Yes
No
Not sure

b) What is the Biosafety Level (BSL) of the Material?*

(Check all that apply.)

BSL-1
BSL-2
BSL-3
BSL-4
Not applicable
Not sure

11. Do you have IBC approval?*

Yes
No
Not sure

Please provide your IBC protocol number:*

12. Will you be modifying the Material?*

Yes
No

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

Yes
No

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

Yes
No
Not Sure

If yes, please list the Sponsor(s)/Funding Sources:*

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

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

Yes
No

b) Type of Funding:*

Government
Start-up/Discretionary (internal)

Award #:*

Title:*

Sponsor:*

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

Yes
No
N/A

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

17. Is the Material otherwise commercially available for purchase?*

Yes
No

18. Confidential Information

a) Do you anticipate RECEIVING any Confidential Information as a part of this transfer?*

Yes
No

b) Do you anticipate SENDING any Confidential Information as a part of this transfer?*

Yes
No

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

Yes
No

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

Yes
No
Not Sure

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

Not Sure
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]

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 all relevant documentation, including Word version of draft agreement from external party, IRB approval letter, etc., here:

Drop files here or

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

Comments

This field is for validation purposes and should be left unchanged.

Material Transfer Agreement (MTA) Request: Incoming MTAs

Instructions

Incoming MTA Form

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