MTA - Tech Comm Agreement Request

General Questions - MTA Request Form
Dear Requestor,

Please proceed to answer the questions below. This request form is set up to alter the questions asked based on your input, so you are not prompted with questions that are not relevant to the agreement you are requesting.

This request form may ask you to upload files relevant to the agreement you wish to request. If any of the files listed below are relevant to this agreement, you should ensure that you know where these files are located and are able to upload them to this form if they are requested.

Possible Files to upload:
- Research Collaboration Agreement (RCA)
- Sponsored Research Agreement (SRA)
- Human Derived Material Consent Form Template
- Original Incoming MTA for 3rd Party Material
- Written Permission from owner/creator of 3rd Party Material (Saved Email)
If you have trouble completing this form, please contact otcagree@umn.edu

Thank you,

Contracts Team
INTERNAL ONLY; office email
example@example.com
Who is filling out this form?*
UMN Principal Investigator Name*

PrefixFirst NameMiddle NameLast NameSuffix
UMN Principal Investigator Email*
example@umn.edu
UMN Principal Investigator Phone Number
Please enter a valid phone number.
Name of Person filling out this form*

PrefixFirst NameMiddle NameLast NameSuffix
Email of Person filling out this form*
example@umn.edu
Phone Number of Person filling out this form
Please enter a valid phone number.
Technology Commercialization Staff Name*

PrefixFirst NameMiddle NameLast NameSuffix
Technology Commercialization Staff Email*
example@umn.edu
Technology Commercialization Staff Phone Number
Please enter a valid phone number.
Helper Date Field; Not Shown; INTERNAL ONLY

MonthDayYear
Date
Date Required By

MonthDayYear
Primary Technology Commercialization Staff Contact

First NameLast Name
Name of the Other Party to the Agreement*
Other Party's Address
Signatory Name

First NameLast Name
Signatory Email
example@example.com

MTA Questions
The Technology Commercialization Office (Tech Comm) will process your request as soon as possible. Tech Comm will contact the Recipient and execute the necessary agreements to facilitate your Material Transfer Request. The process takes a varied amount of time depending on the materials being transferred and working with the Recipient. Once the actual agreement is completed, you will be notified by Tech Comm that you are cleared to transfer the materials to the Recipient. In no event should you ship materials to a 3rd party until you have received approval from Tech Comm.
Is this MTA sending University of Minnesota material to another party or are you receiving material?*

SendingReceivingBoth
Is this outgoing material transfer part of an informal collaboration between you and your colleague at the Recipient Institution?*

YesNo
Do you want to send a draft agreement to the Recipient that includes collaboration terms?*

YesNo
Please check the radio button to acknowledge that you have read the text below*

This agreement should be managed by SPA's UFRA Team rather than by Tech Comm’s Contracts Team. You will need to complete the SPA's UFRA Team's Material Transfer Agreement Routing Form ("MTARF") accessed via this link https://research.umn.edu/units/spa/unfunded-agreements/material-transfer-agreements/mtarf-instructions.

You do not need to complete this Tech Comm outgoing MTA request form.

We request you click the "Submit" Button below so that we have a record of you visiting this form and being redirected to SPA's UFRA Team.
Do you need to transfer the Material to the Recipient because you have hired them to perform a service, such as analyzing the Material?*

YesNo
Please check the radio button to acknowledge that you have read the text below*

An MTA is not needed when the University is sending material under a Purchase Order (PO) or a Contract for Professional Services (CPS) (http://purchasing.umn.edu/purchasing-methods-procedures.html) to a company, who for a fee will analyze or modify the material according to our specifications then return the results and or modified material to the University.

You do not need to complete this Tech Comm outgoing MTA request form.

We request you click the "Submit" Button below so that we have a record of you visiting this form.
Is this outgoing material transfer part of an existing collaboration that has been formalized by a Research Collaboration agreement (RCA) or a Sponsored Research Agreement (SRA)?*

YesNo
Is the exact Material you wish to transfer described in the RCA or SRA as a deliverable?*

YesNo
Please check the radio button to acknowledge that you have read the text below*

An MTA is not needed and the Material can be sent to the Other Party.

You do not need to complete this Tech Comm outgoing MTA request form.

We request you click the "Submit" Button below so that we have a record of you visiting this form.
Please provide a copy of the RCA or the SRA

Cancelof
Is the Recipient using the UMN Material for their internal research?*

YesNo
Is the Recipient evaluating the UMN Material for a potential license?*

YesNo
Are there any restrictions on the Recipient’s use of the Material and/or Confidential Information?*

YesNo
Please provided a detailed description of the restrictions (e.g. specific research project)*
Recipient Scientist Name*

PrefixFirst NameLast NameSuffix
Recipient Scientist Email*
example@example.com
Is the Material biological in nature?*

YesNo
Is the recipient outside of the United States*

YesNo
Is the material a virus, bacterium, fungus, prion or toxin (or toxin sub-unit)*

YesNo
Describe the Material in detail, including species name*
Is the Material a genetic element (such as a plasmid, chromosome, transposon, etc.) that codes for any gene or genes specific to a pathogenic virus, bacteria, fungus, or prion?*

YesNo
Describe the Material in detail, including the pathogenic source organism*
Is the Material a genetic element (such as a plasmid, chromosome, transposon, etc.) that contains a gene or genes coding for any toxin (or toxin sub-unit)*

YesNo
Describe the Material in detail, including the specific toxin(s)*
Is the Material a genetically modified organism that contains any gene or genes specific to a pathogenic virus, bacteria, fungus, or prion?*

YesNo
Describe the Material in detail, including the pathogenic source organism*
Does the Material and/or Confidential Information require any sort of export or import permit in connection with shipment to a foreign country?

YesNoI Don't Know
Please describe as completely as possible*
Is the recipient institution an academic or other not-for-profit institution?*

YesNoI don't know
Provide a complete description of the Material that is to be transferred *
File with Material Description

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Is the material human derived?*

YesNo
Is the Material derived from direct human origin under a University of Minnesota approved or exempted IRB protocol?*

YesNo
What is the IRB number for the approved or exempted protocol ID?*
Who is the Principal Investigator for the approved study?*

PrefixFirst NameLast NameSuffix
Provide a blank copy of the consent form template used to obtain the sample from the subject.

Cancelof
Do the signed donor consent forms exist somewhere in the University (i.e., they haven’t been destroyed)?*

YesNo
Is the Material de-identified?*

YesNo
Are you sending data with the material?*

YesNo
Is the data de-identified in accordance with the HIPAA Privacy Rule’s de-identification standard?*

YesNo
Please check the radio button to acknowledge that you have read the text below*
If you are transferring a Limited Data Set then you will need a Data Use agreement, managed by SPA's UFRA Team rather than an agreement managed by Tech Comm’s Contracts Team https://research.umn.edu/units/spa/unfunded-agreements/overview

You will need to complete the SPA's UFRA Team's Material Transfer Agreement Routing Form ("MTARF") accessed via this link https://research.umn.edu/units/spa/unfunded-agreements/material-transfer-agreements/mtarf-instructions.

If you are transferring Protected Health Information (PHI) to another party then you will need a Business Associate Agreement managed by the University's Health Information Privacy & Compliance Office https://healthprivacy.umn.edu/hipaa-compliance/business-associates

You do not need to complete this Tech Comm outgoing MTA request form.

We request you click the "Submit" Button below so that we have a record of you visiting this form and being redirected to a different University Office.
What is the source of the human derived material if the material was not obtained from direct human origin under a University of Minnesota approved or exempted IRB protocol? *
Did you ever receive or know of any patient identifiers for this human derived material?*

YesNo
Describe the patient identifiers that you received or know of for this Material.*
3rd Party Material Questions

If the Material was obtained from a third party, or if the Material contains or incorporates materials, such as parent strains, that were obtained from a third party, then the incoming terms may prevent UMN from further distributing the Material. Or the incoming terms may impose specific restrictions on how and to whom UMN may further distribute the Materials or modifications of the Materials. These incoming terms must be reviewed to ensure that the UMN follows the incoming terms.
Was the Material created at the University of Minnesota?*

YesNo
What is the 3rd party organization who provided the Material to you?*

A not-for-profit research institutionA repository such as Jackson Laboratory, Addgene, or ATCCA for-profit company
Enter Name of the not-for-profit research institution*
Enter Name of the repository*
Enter Name of the for-profit company*
Please provide a copy of the original incoming MTA for the 3rd Party Material

Cancelof
Provide written permission from the creator/owner of the 3rd party Material allowing UMN to forward the Material to the Other Party to the agreement.

Cancelof
Are you the creator/inventor of the Material?*

YesNo
Who is the person who created the 3rd Party Material?*

First NameLast NameSuffix
Provide written permission from the creator/owner of the 3rd party Material allowing UMN to forward the Material to the Other Party to the agreement.

Cancelof
Does this Material contain or incorporate materials obtained from a 3rd Party or is the Material derived from parent strains obtained from a 3rd Party?*

YesNo
What is the 3rd party organization who provided the incorporated material or the parent strains to you?*

A not-for-profit research institutionA repository such as Jackson Laboratory, Addgene, or ATCCA for-profit company
Enter Name of the not-for-profit research institution*
What is the name of the Person who created the incorporated material or the parent strains?*

First NameLast NameSuffix
Enter Name of the repository*
Enter Name of the for-profit company*
Please provide a copy of the original incoming MTA for the 3rd Party Material

Cancelof
Provide written permission from the creator/owner of the 3rd party Material allowing UMN to forward the Material to the Other Party to the agreement.

Cancelof
Has the Material been disclosed as part of an invention to the Technology Commercialization Office?*

YesNo
Please use this link to the Tech Comm database to see your case information. Login using your UMN credentials.
What is the invention number?
Is the Material itself to be kept confidential (i.e. – not published or publicly disclosed?)*

YesNo
Does the Material incorporate or was it made with Confidential Information provided by a third party?*

YesNo
Please explain, and provide the source Institution of the third-party Confidential Information *
Are you sharing confidential information in addition to the Material?*

YesNo
Please give a brief, non-confidential summary of the Confidential Information to be shared*
Will the Other Party share confidential information with UMN?*

YesNo
Do you and your research team members understand what information will be provided by the Other Party to UMN that will need to be kept confidential?*

YesNo
Do you have processes in place to ensure that neither you nor anyone in your lab or under your direction will disclose confidential information that the Other Party provides to UMN?*

YesNo
Please check the radio button to acknowledge that you have read the text below*

Please contact the University’s Office of the General Counsel, Arnie Frishman frish003@umn.edu to discuss your obligations under this MTA.
Was the Material developed with funding from an outside source*

YesNo
Provide the name of the funding organization (for example: NIH grants)*
Notes/Miscellaneous information
Additional Files

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Should be Empty:

General Questions - MTA Request Form

MTA Questions

3rd Party Material Questions