Download Simple Letter Agreement for the Transfer of Materials - WUSTL-ICTS

Letter Agreement for the Transfer of Human Specimens
The Washington University, Translational Cardiovascular Biobank & Repository (TCBR)
For Academic/Non-Profit use only
Whereas, The Washington University, One Brookings Drive, St. Louis, MO, U.S.A (PROVIDER) through the TCBR
possesses coded human biological samples (MATERIAL); and
Whereas, the non-profit institution listed below (RECIPIENT) has requested the MATERIAL further described as:
_;
For use in the following not-for-profit research project (PROJECT):
_
In response to RECIPIENT’s request for the MATERIAL the PROVIDER asks that the RECIPIENT agree to the
following before the RECIPIENT receives the MATERIAL:
1. The above MATERIAL is the property of the PROVIDER and is made available as a service to the research
community. MATERIAL provided pursuant to this Agreement was collected or will be collected in accordance with the
standard participant informed consent procedures of the PROVIDER in effect at the time of collection and subject to
approval by the PROVIDER’s IRB. MATERIAL provided to RECIPIENT by PROVIDER will not contain personally
identifiable participant information and will not include “Protected Health Information” (“PHI”) as defined in 45 C.F.R.
section 164.501 unless a data use agreement has been executed.
2. THIS MATERIAL IS NOT FOR USE IN HUMAN SUBJECTS.
3. The MATERIAL will be used for not-for-profit research purposes in conduct of the above PROJECT only.
4. THE MATERIAL WILL NOT BE FURTHER DISTRIBUTED TO OTHERS without the PROVIDER’S written
consent. The RECIPIENT shall refer any request for the MATERIAL to the PROVIDER.
5. RECIPIENT agrees to the following requirements of the TCBR:
a. Complete an Application for Services form that has been approved by the TCBR Advisory Committee prior to tissue
disbursement.
b. MATERIAL that is not used up in its entirety during the course of the PROJECT will be destroyed at the conclusion
of the PROJECT.
c. Provide a copy of any publication which contains experimental results obtained from the use of the MATERIAL.
d. Deposit raw experimental data, after publication, into the TCBR data repository, which is obtained from the use of
the MATERIAL, particularly those data which will not be used further in presentations or publications by the
RECIPIENT.
e. Acknowledge the TCBR and its affiliated grants, NIH/CTSA grant UL1 TR000448, a grant from the Children’s
Discovery Institute of Washington University and St. Louis Children’s Hospital, and funds from the Richard J.
Wilkinson Trust, in any presentation or publication that may result from this research.
f. Should funding result from this research now or in the future, please notify the TCBR with details so we may report
productivity derived from our resources to the NIH.
6. The RECIPIENT agrees that it will not have or seek access to any identifiable information (such as the key to the code)
under any circumstances. The RECIPIENT agrees to never use the MATERIAL or any substance derived from the
MATERIAL (e.g. DNA, RNA or any information provided with the MATERIAL) to attempt to ascertain the identity of
the individual from whom the MATERIAL was obtained.
7. Any MATERIAL delivered pursuant to this Agreement is understood to be experimental in nature and may have
hazardous properties and may carry transmissible infectious agents. NO SCREENING FOR INFECTIOUS
AGENTS HAS BEEN PERFORMED ON TISSUES OR BODILY FLUIDS PROVIDED BY THE WASHINGTON
UNIVERSITY SCHOOL OF MEDICINE TRANSLATIONAL CARDIOVASCULAR BIOBANK &
REPOSITORY. THE RECIPIENT’S SCIENTIST MUST TAKE APPROPRIATE PRECAUTIONS. THE
PROVIDER MAKES NO REPRESENTATIONS AND EXTENDS NO WARRANTIES OF ANY KIND, EITHER
EXPRESSED OR IMPLIED. THERE ARE NO EXPRESS OR IMPLIED WARRANTIES OF MERCHANTABILITY
OR FITNESS FOR A PARTICULAR PURPOSE. Unless prohibited by law, RECIPIENT assumes all liability for claims
for damages against it by third parties which may arise from the use, storage or disposal of the MATERIAL except that, to
the extent permitted by law, the PROVIDER shall be liable to the RECIPIENT when the damage is caused by the gross
negligence or willful misconduct of the PROVIDER.
8. The RECIPIENT agrees to use the MATERIAL in compliance with all applicable statutes and regulations.
9. The MATERIAL is provided with a fee delineated in the Application for Services. If a fee is required, the amount
will be indicated here:
The RECIPIENT and RECIPIENT SCIENTIST must sign this letter and return one signed copy to the PROVIDER. Upon
receiving this fully executed agreement and after approval of the completed Application for Services form, the
PROVIDER will then send the MATERIAL.
SIGNATURE PAGE FOLLOWS:
TCBR_MTA_v.032414
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RECIPIENT INFORMATION and AUTHORIZED SIGNATURE
Printed Name of Recipient Scientist: Click here to enter text.
Printed Name of Recipient Institution: Click here to enter text.
Address: Click here to enter text.
Printed Name of Authorized Official: Click here to enter text.
Title of Authorized Official:Click here to enter text.
Signature of Authorized Official:
Date: Click here to enter text.
.
Certification of Recipient Scientist: Although not a legal party to this Agreement, I have read and understood the
conditions outlined in this Agreement.
Signature of Recipient Scientist:
.
TCBR_MTA_v.030813
2 of 2
Date: Click here to enter text.