SUBMISSION FORM RESEARCH Confidentiality /Non-Disclosure Agreements (CDA/NDA)

Basic Information

1. / Principal Investigator:
2. / Department/Institute/Center that will be administratively responsible for this Agreement: / Department/Institute/Center Name:
Department/Institute/Center ID:
3. / Is the draft of the agreement attached? / Yes, Draft agreement attached
No, Pitt to Generate First Draft
No, this is an Addgene Order
No, this is an NCI dbGaP Study
No, this is an NCI Development Therapeutics Study
Other, please explain:
4. / Title of Submission:
5. / Department Administrative Contact: / Name:
E-Mail:

Contracting Party Information[1]

1 / Contracting Party Name:
2. / Legal Contact Name:
3. / Legal Contact E-Mail Address:
4. / Legal Contact Phone Number:
5. / Scientific Contact Name:
6. / Scientific Contact E-mail:
7. / Does the Principal Investigator have a financial relationship with any of the Contracting Parties listed above that is or should be disclosed on your University of Pittsburgh Conflict of Interest disclosure form? / Yes
No
If Yes, please explain:

General Information

1. / Is this CDA/NDA to permit discussions solely regarding commercial licensing activity with the other party? / Yes
No
If YES, please direct your request to the Office of Technology Management (OTM)
2. / Is this CDA/NDA related to your potential private consulting activity with the other party? / Yes
No
If YES, The Office of Research cannot review this CDA/NDA. You should review any consulting arrangement with your Chair.

Related Agreements

1. / Are there any other agreements/funding/materials applicable to the receipt or disclosure of the confidential information (consider all that apply, i.e., Sponsored Research Agreement, Government or Other Grant, CDA, License, MTA, Subcontract, Other Agreement)? / Yes
No
If Yes, please provide the details – including the Institution Number or Project Number:

Confidential Disclosure

1. / Provide the purpose of the information exchange:
2. / Are you disclosing non-public information? / Yes
No
If Yes:
Describe the information you are disclosing including - who developed the information and whether you know of any restrictions related to its dissemination:
Is the non-public information related to an invention under disclosure to or patented by the University Office of Technology Management (OTM)? / Yes No
If Yes,
OTM Staff Member:
OTM Case Number:
3. / Are you receiving non-public information? / Yes
No
If Yes:
What information is the other party disclosing to you?
Are there any other parties to the CDA/NDA who are not under your direct supervision? / Yes No
If Yes, list all individuals:

Clinical Trial Agreement

1. / Is the specific purpose of this CDA/NDA to discuss a clinical trial agreement or protocol? / Yes
No
2. / If Yes, select all that apply: / The study is investigator initiated. This means a Pitt faculty member has had substantive intellectual input into the protocol design; OR
The trial is industry designed and sponsored but the experimental drug or device being evaluated in the trial:
~ emits ionizing radiation; and/or
~ involves a gene transfer intervention; and/ or
~ involves a transgenic xenotransplant; OR
The study involves no use whatsoever of UPMC space, patients or records;OR
The PI has a Pitt regular faculty appointment but lacks a UPMC/UPP appointment; OR
The study is being financially supported by industry but has been designed by a collaborator at another non-profit institution.
None of the above apply to this trial. Please contact: the UPMC OSPARS OFFICE 412-647-4461 for instructions on submission.

Additional Information

1. / Additional information relevant to the review of this request, including any time constraints:

Submit the requested materialsby Email to

All fields on this form are required.

Forms missing information or submission packages that do not include requested documentation will be returned to the submitter.

Form Revision Date: 11/2014

Page 1

[1] If there are multiple contracting parties for this agreement, please attach a list (including legal contact information) to your submission package.