If another lab is sending you research materials and you need an MTA, please fill out this form.
* indicates required fields.
Principal Investigator *
SU Lab Contact/Admin Name & E-mail *
Provider Institution/Company Name *
Material Provider Name & E-mail *
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?
Does the Material include personally identifiable information (PII) or personal health information (PHI) or other data about a living person? If so, please describe
Human stem cell, embryos, or oocytes (SCRO)
Radiologically hazardous (CRA/SMN)
Obtained from a living person (IRB)
Live vertebrate animals (APLAC)
Infectious or Biohazardous not including Viral Vectors (APB)
rDNA non-exempt under NIH guidelines (APB)
By checking this box, I confirm that the material is covered under an approved APB protocol.
FOR APLAC - Please describe how the material(s) will be used in live animals. For new rodent strains, describe the known phenotypes of each strain (that is, why the strain will be used for your study), and include any detrimental phenotypes that may require special care or monitoring.
Please provide protocol #(s) for the above selection(s)
Industrial Affiliates Program
Federal contract(s) or grant(s)
Name the above funding source(s) for your research project
Advisory Board Member or Board of Directors
Ownership of stock or stock options
Attach the Word version of the MTA, if available. Do not have the PI sign the MTA until it has been reviewed by ICO:
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: email@example.com
Please skip. Do not fill this out.