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.

CONTACTS

Principal Investigator

Department *

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.

How will you use the Material?

Will you modify the Material?

Yes

Is the Material commercially available for purchase?

Yes

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

Yes

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

Yes

Compliance

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

Human stem cell, embryos, or oocytes (SCRO)

Infectious or Biohazardous (APB)

Live vertebrate animals (APLAC)

Obtained from a living person (IRB)

Radiologically hazardous (CRA/SMN)

rDNA non-exempt under NIH guidelines (APB)

Please provide protocol #(s) for the above selection(s) :

Research

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

CIRM

Federal contract(s) or grant(s)

Gift fund(s)

Industry sponsor(s)

Nonprofit grant(s)

Other

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

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

Yes

Do any of the involved Stanford researchers have a financial relationship with the Material Provider (check all that apply):

Advisory Board Member or Board of Directors

Consulting

Ownership of stock or stock options

Other

Have all participating Stanford researchers who are currently identified, including postdocs, students and visiting scholars, signed Stanford’s Patent and Copyright Agreement form (SU-18 or SU-18A)? *

Yes

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:

Your E-mail *

Special instructions:

After you click “Submit Form” below, you will receive an e-mail 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