Download Graduate and Research Affairs

SAN DIEGO STATE UNIVERSITY
GRADUATE AND RESEARCH AFFAIRS
REQUEST FOR APPROVAL OF MATERIAL TRANSFER
This form must be submitted to the Division of Research Affairs along with the MTA.
Provider Organization:
Recipient Organization:
Provider Scientist:
Recipient Scientist:
Phone:
Material(s) Identification (Scientific Name):
Name the material in non-scientific terms i.e., plasmid, vector, bacteria, virus, gene, cell line, human embryonic stem cell
line, human blood or tissue, animal tissue, live animal name, chemical compound, software, database, gene chips or other
devices, etc.
Is this material transgenic in nature?
Yes
No
1. Is the development or use of these materials connected in any way with a
grant or contract awarded through the SDSU Research Foundation?
Yes No
If so, please give the Fund #_________________
2. If SDSU is the RECIPIENT Organization:
a. Will this material be inserted into live animal models?
Yes No
b. Are you receiving live animals?
Yes No
If so, either a new Animal Protocol Form (APF) or an amendment to an existing APF will need to be reviewed and
approved by the Institutional Animal Care and Use (IACUC) before the animals can be used or the material can be inserted
into the animals. Depending on the nature of the material, Institutional Biosafety Committee (IBC) approval may also be
needed.
Please note: The Office of Laboratory Animal Care will need the animal health reports from the providing entity prior to
the receipt, a minimum of 10 days prior to an international shipment and 5 days prior to a domestic shipment. Contact
Tony Slimp at [email protected] or (619) 594-5421.
Contact Christine Cook in the Division of Research Affairs for IACUC or IBC protocol information [email protected] or 619594-0905.
c. Are any environmental, health risks or toxicity associated with the use of the material?
c. Will this material be inserted into human cells?
d. Will this material be used in recombinant DNA methods?
e. Will this material be combined with infectious microorganisms?
f. Will this material be used to produce toxins in-vivo or in-vitro?
Yes No
Yes No
Yes No
Yes No
Yes No
If you answer yes to any of these questions, either a new Biological Use Authorization (BUA) form or an amendment to an existing BUA
will need to be reviewed and approved by the Institutional Biosafety Committee (IBC) before the material can be used in your research.
Information can be found at: http://gra.sdsu.edu/research/ibc, or by contacting the Biosafety Officers Millie Tran or Sheryl Major
at email [email protected] or (619) 594-6778.
Contact Christine Cook in the Division of Research Affairs for IACUC or IBC protocol information [email protected] or 619594-0905.
c. Will SDSU be required to indemnify or “hold harmless” the provider for use of the material?
Yes No
d. Are any inventions or commercially useful modifications
a likely or possible outcome of your use with the material?
Yes No
f. Are any publication restrictions or conditions of confidentiality requested
by the provider organization?
Yes No
3. If SDSU is the PROVIDER Organization:
Please note: Shipping clearances from the applicable department (i.e. Environmental Health and Safety or the Office of
Laboratory Animal Care may be needed prior to shipping the material).
a. Are fees or handling charges involved in the transfer of the material?
Yes No
If so, what is the fee: ____________________________________
Yes No
b. Is this material proprietary to you? If so, use the MTA for proprietary material.
Yes No
c. Have you submitted an SDSU Intellectual Property Disclosure for this material?
Yes No
d. Do you hold a patent for this material? If so, use the MTA for proprietary material.
Yes No
e. Are animals the materials transfer being transferred?
Yes No
Please note: The Office of Laboratory Animal Care will send the animal health reports to the receiving
entity prior to shipment, a minimum of 10 days prior to an international shipment and 5 days prior to a
domestic shipment. Contact Tony Slimp at [email protected] or (619) 594-5421.
f. Does the material pose any environmental, health or toxicity risks?
Yes No
Information can be found at: http://gra.sdsu.edu/research/ibc, or by contacting the Biosafety Officers Millie Tran or
Sheryl Major at email [email protected] or (619) 594-6778.
If so, has this been disclosed to the recipient? Yes No
g. Does this transfer involve biohazardous materials or recombinant DNA? (Packaging and shipping regulations apply)
h. Has this material been sent to you by another institution, if so provide the institution name and providing scientist
name.__________________________________________ Unless the MTA under which you received the material states
otherwise, you must obtain permission from the original providing institution and scientist.
To ensure material being transferred in this MTA have appropriate safeguards in place for environmental, health, biohazard, toxicity risks
or transportation and/or permit requirements the SDSU Department of Environmental Health and Safety must review the MTA, contact
http://bfa.sdsu.edu/ehs or (619) 594-6778. Please contact the Division of Research Affairs (619)594-0905 with questions related to this
Material Transfer Agreement and associated clearances. Your signature below acknowledges your understanding of responsibilities
associated with the transfer of materials and your agreement to comply with institutional commitments to federal assurances which guide
the responsible conduct of research.
Signatures:
SDSU Scientist
Date
Director, Division of Research Affairs
Date
Department Chair
Date
Last Modified August 2010