Newcastle University (Outgoing Materials)

Material Transfer Agreement (MTA) Questionnaire for Outgoing Materials.

Academics must complete the following to determine suitable terms for the transfer of the Material.

Please note: This Form must be filled in by the Principal Investigator or another individual on the authority of the Principal Investigator. Incomplete answers may delay processing.

Name of Newcastle Academic transferring Material, Academic Unit: *
Name of receiving researcher: *
Email address of receiving researcher *
Name of organisation receiving the Material: *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Brief description of the Material (including amount being transferred and Material reference number/name) *
1. Is the Material to be transferred a: compound, hybridoma or a sample of human tissue? *
compound hybridoma a sample of human tissue none of these
2. Is there a fee being charged for the Material? *

2. Is there a fee being charged for the Material? Yes No
If yes, please state the amount below
3. Was the Material generated outside of Newcastle University? (eg at another University). *

3. Was the Material generated outside of Newcastle University? (eg at another University). Yes No Don't know
If yes, please provide brief details below.
4. Are the materials coming out of a Biobank and if so, which one? *

4. Are the materials coming out of a Biobank and if so, which one? Yes No Don't know
If yes, please provide details
5. Was the Material, or any component part of the Material (e.g. the original cell line if transferring an engineered cell line) obtained under another contract? (e.g. under an MTA or a contract for receipt of a cell line) *

5. Was the Material, or any component part of the Material (e.g. the original cell line if transferring an engineered cell line) obtained under another contract? (e.g. under an MTA or a contract for receipt of a cell line) Yes No Don't know
If yes, please provide brief details below.
6. Is the proposed transfer to a company (eg a pharma company) or an organisation working with a company (eg a research institute to carry out contract research or research in collaboration with industry)? *

6. Is the proposed transfer to a company (eg a pharma company) or an organisation working with a company (eg a research institute to carry out contract research or research in collaboration with industry)? Yes No
If yes, please provide brief details below. *
7. Who is responsible for the cost of shipping the materials? *
8. Is the transfer for collaborative purposes? (eg where you want access to the results). *

8. Is the transfer for collaborative purposes? (eg where you want access to the results). Yes No
If yes, please provide brief details of the proposed collaboration.
9. Please provide details as to how the creation or collection of the Material has been funded giving BH numbers if know.
10. Has the Material been commercialised or is in the process of being commercialised, or does the Material have commercial potential? (eg is there a patent application associated with the Material or has the Material been licensed or otherwise provided to a company already). *

10. Has the Material been commercialised or is in the process of being commercialised, or does the Material have commercial potential? (eg is there a patent application associated with the Material or has the Material been licensed or otherwise provided to a company already). Yes No Don't know
If yes, please provide brief details.
If you have been provided with an MTA from the Receiving Party/Parties, please provide.
Please enter today's date. * / DD / MM YYYY
Email *

Please enter your email address. You will receive a copy of the submission for your records.
Name and email details of person to be copied into all emails if needed
I confirm that I am the Principal Investigator named above or another individual submitting on the authority of the Principal Investigator named above. *
Confirmed.
Data Protection Statement

Please Note The information provided above will be specifically used for the negotiation of suitable contract terms with the parties named in the above questionnaire. The University’s Data Protection Policy can be found at: https://newcastle.sharepoint.com/docs/Information%20Data%20and%20IT%20Policies/Forms/AllItems.aspx?id=%2Fdocs%2FInformation%20Data%20and%20IT%20Policies%2FData%20Protection%20Policy%20Jan%202019%2Epdf&parent=%2Fdocs%2FInformation%20Data%20and%20IT%20Policies

Newcastle University (Outgoing Materials)

Newcastle University (Outgoing Materials)

Data Protection Statement