Material Transfer Agreement (MTA) Quick Form, Incoming MSSM PI Name * Provider Institution/Company * Provider Contact Provider Contact Email * Name of Material Requested * Type of Material Requested * Compound Cell Antibody Animal Patient Sample DNA Other If Other above, please describe Short description of how material be used. *
Greatest length of time the research will require. * Will you also receive confidential or proprietary information from the provider? * Will material be used in conjunction with other materials or with equipment received or requested (not purchased) from other providers? * Will your lab collaborate (either at MSSM or another academic institution or a company) on the project in which the material will be used? * Will your lab receive funding from any third parties, industrial, government (Federal grant such as an NIH grant, State grant such as from NYSTEM) or philanthropic foundations, in connection with this research? * Do you have any issued or pending patents, or have you ever filed an invention disclosure related in any way to the research? * Is the material to be received a controlled substance that requires state and/or federal government approval for import, receipt, or use? * If you will receive human derived samples or tissue, has the MSSM IRB specifically approved the use of the materials by your lab? * Do you have any concerns regarding the terms of the MTA provided by the provider or otherwise regarding this material? * If Yes above, please describe
