NCSU MTA REQUEST FORM – INCOMING

1)Identify the Materials

2)Provide a brief description of how the Materials will be used.

3)Will you make any contributions that might potentially result in new IP?

4)If incoming Material(s) will be used with other NCSU and/or non-NCSU materials (“Other-Materials”), please list the Other-Materials that will be used along with the sources forsuch Other-Materials including agreement numbers.

5)Please list by grant number or account number all funding sources (federal and non-federal) used that will support your research using the Material.

(a)If OtherNCSU Materials will be used in the research, please list by grant number or account number all funding sources (federal and non-federal) that were used to develop the NCSU materials.

6)Will the Material be used in conjunction with Other-Materials from third parties? If so, what are these Other-Materials and who provided them? Were MTAs signed for these Other-Materials?

7)Will the Material be used in animals or humans? If yes, please provide the IACUC and/or IRB Protocol No.

8)Will the Materials be used for military or nuclear applications?

9)Do any of the following apply to the Material?

  • is a recombinant DNA in an organism(s),
  • will be used to creates transgenic plants or animals,
  • is a human and other primate-derived substances (blood, body fluids, cell lines or tissues),
  • is an organism(s) and/or virus infectious to humans, animals or plants (e.g. parasites, viruses, bacteria, fungi, prions,
    rickettsia);
  • is a biologically active agent(s) (i.e. toxins, allergens, venoms) that may cause disease in other living organisms or cause significant impact to the environment or community.

If yes, please provide IBC approval #______.

8)Will you be receiving any Hazardous Materials? If so, do you have a lab safety plan? If Yes, please provide Safety Plan #______

10)Please provide contact information for the Providing Scientist and for their MTA Administrative Contact if known:

11)Is the Material on Commerce Control List, or controlled by the Export Administration Regulations (EAR) or International Traffic in Arms Regulations (ITAR) Office of Foreign Assets Control or other Export Control Laws, or other Federal and/or State restrictions on transfer of the Material?

12)Will any foreign national have access to the Material while it is in your possession? If yes, please identify the individual and country of origin.

Ver.9.20.16