Material Transfer Agreement Request Form for OUTBOUND Material

Submitter Name*

First Last

Title

Email*

Phone

I am the JHU Faculty/Inventor.*

Yes
No

If "NO," please fill out the following JHU Faculty/Inventor information: First & Last Name, Title, Email, Phone Number

Receiving Company/Institution Name*

Receiving Company/Institution Address

Recipient Scientist Contact Name*

Recipient Scientist Contact Title

Recipient Scientist Email*

Recipient Scientist Phone

Administrative Business/Legal Contact Info (First & Last Name, Title, Email, Phone Number)*

Provide the exact name of the material*

Check all material types that apply*

If you checked "Other," describe the material type(s) here.

If the material is a cell line, is it stored at JHU Cell Center?

Yes
No
Uncertain

Does the material or research relate to a JHU Report of Invention?

Yes
No
Uncertain

If "YES," please provide the Report of Invention number(s) if known.

If the material has been published, provide journal citation link/title. If not, please type "NO"*

In either event, will confidential information relating to the material be shared with the recipient?

Yes
No
Uncertain

Provide a description of the recipient’s research*

Use of the material*

Will be provided for the purpose of product testing and evaluation for the providing organization.
Is a tool, kit or instrument that will be used in the conduct of research.
Is a reagent.
Will be used to make progeny, unmodified derivatives or descendant copies of the material(s).
Will be modified or used to produce modifications.
Other

Check all that apply.

If "Other," describe the use of the material

Will your material be used for non-commercial, unrestricted, internal research purposes only?*

Yes
No
Uncertain

If "NO," briefly describe the recipient’s use of the material

If there is a limit on how long the material may be used, enter it here (optional)

Is the material hazardous, cDNA or otherwise classified as a “dangerous substance” under federal regulations?*

Yes
No
Uncertain

Will the material leave the United States or is it otherwise subject to federal export control regulations (ITAR or ETAR)?*

Yes
No
Uncertain

Was the material solely created at JHU?*

Yes
No
Uncertain

If "NO," where was the material created and by whom?

Was the material created using materials from another laboratory at JHU, another university, a company, etc.?*

Yes
No
Uncertain

If "YES", identify the material, the source and indicate whether there is an associated MTA. (Note: This is not needed for off-the-shelf materials purchased without an MTA)

Was the research in which the material was created supported by funds from an external source (e.g. federal funding, sponsored research or foundation support)?*

Yes
No
Uncertain

If "YES," identify the source. Please be specific

Is the material being provided as a straightforward transfer of materials and not as a collaboration with the recipient PI in any other way?*

Yes
No
Uncertain

If "NO," did you develop the protocol?

Yes
No
Uncertain

If "NO," do you expect joint publication (co-authorship) of research results?

Yes
No
Uncertain

Describe how the JHU Provider PI and Recipient Scientist PI will each contribute to the collaboration

Has the material already been sent to the recipient scientist?

Yes
No

Please specify any special circumstances or other comments, information, or concerns that JHTV should be aware of prior to facilitating this MTA

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Max. file size: 20 MB.

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Max. file size: 20 MB.

Upload/Attach Additional File Here.

Max. file size: 20 MB.

Upload/Attach Additional File Here.

Max. file size: 20 MB.

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Material Transfer Agreement Request Form for OUTBOUND Material

Note: If the research involves human subjects OR is being funded by the provider of the materials, DO NOT USE THIS FORM. Contact your school’s Office of Research Administration (ORA) for assistance.

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