Human Material Transfer Agreement Outgoing Form

If your lab is sending out human material for research purposes, please fill out this form.

* indicates required fields.

CONTACTS

Principal Investigator *

Department *

Lab Contact/Admin Name & E-mail *

Recipient Name & E-mail *

Special instructions

MATERIALS

Describe/list the human materials you wish to send out

Does the Material include personally identifiable information (PII) or personal health information (PHI) or other data about a living person? If so, please describe

Will the Material be used to further develop an invention that has been disclosed to the Stanford Office of Technology Licensing?

Yes

COMPLIANCE

Have you requested IRB review? *

Yes

Please provide IRB protocol #(s) :

Upload IRB approval/exemption letter:

Additional document:

RESEARCH

Please provide a short justification for the scientific value of the transfer *

Will you receive shipping payment or another fee from the Recipient?

Yes

Select the funding source(s) for the research with the material. (Check all that apply)

CIRM

Gift fund(s)

Federal contract(s) or grant(s)

Industry sponsor(s)

Nonprofit grant(s)

Other

Name the above funding source(s) for your research project

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

Yes

Do any of the involved Stanford researchers have a financial relationship with the Recipient? (Check all that apply)

Advisory Board or Board of Directors member

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 (SU-18 or SU-18A)? *

Yes

Your E-mail *

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