Appendix B

Instructions for sending Human Tissue to an Institution for Research Purposes

You should use this form where Human Tissue is to be transferred from Sussex to an academic or research institution for research purposes. This form should not be used for the purpose of sending Human Tissue to a service provider for diagnostic or testing purposes.

  1. QUESTIONNAIRE

SUSSEX’ PRINCIPAL INVESTIGATOR DETAILS
Name / School
Office Address
Telephone No. / Email
RECIPIENT INSTITUTION DETAILS
Name of Recipient Institution
Name of School/Department
Address of Recipient Institution
Name of Contact at Recipient Institution
Email for Contact
CHECKLIST
1. / Is the Recipient Institution Licensed by the Human Tissue Authority? /

2. / If the answer to item 1 is “Yes”, please provide the Recipient Institution’s Human Tissue Authority Licence No.
3. / Is the transfer of the Materials to the Recipient Institutioncovered by ethical approval given eitherto the Recipient or to Sussex by a research ethics committee which, within the UK, is recognised under the Human Tissue Act 2004? /

If “Yes”, please attach a copy of the letter of approval.
THE MATERIALS
4. / Description of Materials to be Transferred
(please be as detailed as possible)
5. / Quantity of Materials to be Supplied
6. / Is there or will there be “appropriate consent” from each Donor, as required by the Human Tissue Act 2004,which permits the use of the Materials in the Recipient Institution’s research? /

If “No”, please explain why consent is not required
7. / If the Materials have been or will be obtained by Sussex from HumanSubjects, please provide a copy of the ethical approval under which the Materials have been or will be obtained and tick the box on this row in the column opposite. /
8. / Were the Materials obtained by Sussex from a third party? /

9. / If you have answered “Yes” to item 8, please provide the name of the third party and provide a copy of the MTA and/or other document(s) (e.g. NDA, research collaboration agreement) under which the Materials were obtained. / Name of third party who supplied the Materials to Sussex:
(Please attach copy of MTA or other document under which the Materials were obtained).
10 / If you have answered “Yes” to item 8, please provide a copy of the ethical approval under which the Materials have been or will be obtained and tick the box on this row in the column opposite. /
11. / Were the Materials obtained by Sussex using funding from a third party? /

12. / If you have answered “Yes” to item 11, please provide the name of the third party whose funding was used to obtain the Materials and Sussex’s research project code for the relevant project or other information sufficient to identify the project.
13. / Are the materials known to be toxic, infectious or in any other way dangerous?
14 / What conditions of storage will apply to the Materials?
USE OF THE MATERIALS BY RECIPIENT INSTITUTION
15. / What will the Recipient Institution do with the Materials? (please give a description of the research which the Recipient Scientist may carry out using the Materials – this will go into the MTA. Please also attach any protocol or outline of the research)
16. / What results will be, or are likely to be generated from the Recipient Institution’s use of the Materials?
In your opinion, how likely is it that the Recipient Institution’s research using the Materials will generate any invention, or other result that might have commercial value or be used in future research which will have commercial value? / Extremely unlikely
Unlikely
Possible
Difficult to say
17. / For how long will the Recipient Institution need to retain the Materials?
18. / When the Recipient Institution has finished using the Materials, should they destroy any remaining Materials and any data provided with them or return Materials and data tot Sussex?
  1. DECLARATION BY THE PINCIPAL INVESTIGATOR

I have checked and satisfied myself that the transfer of these Materials is permitted by the consent given by the Donor and that there is no other reason to the best of my knowledge why the transfer to the Recipient Institution should not be made.

Signed by the Principal Investigator

Date of signature______

Please email a scan of this form, with an electronic copy of the research summary or protocol (if applicable) and other documents required to or send a hard copy of all documents to Contracts & IP, 2nd Floor, Falmer House, marked as “MTA Request”. The Contracts Team will then, provided it is satisfied with the information you have provided,prepare an outgoing MTA in Sussex’s standard form and send this to you for forwarding to the Recipient Institution. The matter will be allocated to a member of the Contracts Team who will contact you if further information is required by the Contracts Team and this will also be the person to whom you refer any questions or concerns that may be raised by the Recipient Institution.

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