If you are receiving loaned equipment, please fill out this form.
* indicates required fields.
Principal Investigator *
SU Lab Contact/Admin Name & E-mail *
Lender Company Name *
Lender Contact Name & E-mail *
Name of Equipment / Manufacturer / Model / Serial # : *
Where will the equipment be installed: Stanford University, SHC or LPCH?
If the answer is SHC or LPCH, please provide the location and contact information of the SHC or LPCH person
Will Stanford University, SHC or LPCH receive ownership or rights to purchase the equipment? If so, explain how this will be carried out
Will the equipment be installed in areas where patients are located?
Who will install and/or pay for installation of the equipment?
Will the equipment be modified after installation? If so, how will it be modified and who will be responsible?
Who will de-install and/or pay for the return of the equipment?
What is the estimated total value of the equipment? *
What is the start and end date of the equipment loan?
Who will pay for maintenance during the loan period?
Will the loan include Lender Technical information or documentation apart from that needed to operate the Equipment? Explain. *
Will equipment be used for research purposes? If so, provide an estimate of % time
Will equipment be used clinically? If so, provide an estimate of % time
Will the equipment be used for research with human subjects? If so, provide IRB protocol # :
If yes to #24, will the software include source code? Describe.
Will the software be modified? If so, who will do the modification and how?
If the equipment is not FDA-approved and will be used with human subjects, will you (PI) be the Sponsor? If so, who will hold the IND for use of the equipment? *
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 agreement, if available. Do not have the PI sign the agreement 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
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