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Material Transfer Agreement Intake Form

If another lab is sending you research materials and you need an MTA, please fill out this form.

* indicates required fields.

Contact

Principal Investigator *

Lab Contact/Admin Name & E-mail

Material Provider Name & E-mail *

Materials

Describe/list the Material(s) you wish to receive. Please indicate whether the Material is a cell line, plasmid, mouse, etc.

Is the Material commercially available for purchase?

Yes

No

Research

How will you use the Material?

Will you modify the Material?

Yes

No

Will the Material be used in conjunction with any material received from a different provider under an MTA?

Yes

No

Will the Material be used to further develop an invention that has been disclosed to Stanford OTL?

Yes

No

Select the funding source(s) for the research project (check all that apply):

CIRM

Industry sponsor(s)

Federal contract(s) or grant(s)

Nonprofit grant(s)

Gift fund(s)

Other. Please describe:

Specify the name(s) of the above funding source(s) for your research project:

Compliance

Do any of the involved Stanford researchers have a financial relationship with the Material Provider such as:

Consulting

Serving on an Advisory Board or Board of Directors

Ownership of stock or stock options

Other

Have any of the involved Stanford researchers received gift funds from the Material Provider?

Yes

No

Is the Material, or will the Material be used with material that is (check all that apply):

Human stem cell, embryos, or oocytes (SCRO)

Live vertebrate animals (APLAC)

Obtained from a living person (IRB)

Radiologically hazardous (CRA/SMN)

rDNA non-exempt under NIH guidelines (APB)

Infectious or Biohazardous (APB)

Please provide protocol #(s) for the above selection(s) (or enter N/A for none):

Upload MTA & Additional document(s)

Attach the Word version of the MTA, if available. Do not have the PI sign the MTA until it has been reviewed by ICO:

Additional document:

Additional document:

Your E-mail *

Special instructions for us:

After you click “Submit Form” below, you will receive an email confirmation. We will contact the Principal Investigator and individual(s) identified as the Lab Contact/Admin about next steps. For questions, please contact ico@stanford.edu.

Please skip. Do not fill this out.