PI QUESTIONNAIRE
For receiving research materials under an MTA

Please fill out this questionnaire in connection with your request for receiving research materials. CSRL requires all the information in this form before it can review and sign any Material Transfer Agreement. Please direct your questions and return the completed questionnaire with attachments to:
  Renee Tetrault , CSRL
tel: 617-954-9375
fax: 617-954-9361
rtetrault1@partners.org

[To download this form rather than submitting it online, please see below.]
If you are using Netscape 4.7 to view this site, do not resize this window or refresh the page while entering your answers online.


1.
Principal Investigator requesting material:
  Name:
  Title:
  Phone number:
  Fax number:
  Email address:
  Building/Room Number:
  Department/Division:
  Shipping Address
for materials:
(if different from Building/Room number)
  Is the Principal Investigator an HHMI (Howard Hughes Medical Institute) Investigator?
Yes No

2.
BWH Scientist requesting material:
  Name:
  Phone number:
  Email address:

3.
Institution or Company providing material:
(e.g. provider scientist or the institution/company representative who deals with technology transfer)
  Institution Name:
  Institution Address:
  Contact Name:
  Contact Phone:
  Contact Fax:
  Contact Address:
  Contact Email:

4.
Did you initiate request for the material , or did the provider solicit your use the material ?

5.
If the provider of the material is a company, do you or any member of your family or household hold any equity (stocks, securities, options, or similar interests) in this company?
Yes No

If Yes, please explain:

6.
Specific name (Ex. "2E12", "DM34", etc.), as well as general type (Ex. Antibody, KO mice, etc.), of the material requested:

If the material is a mouse, does the material contain any Cre-Lox Materials ?
Yes No


7.
Is material currently in your possession?
Yes No

If Yes, please explain:

8.
Is material available commercially through a reagent bank or any other source?
Yes No

If Yes, please explain:

9.
Has the material been described in a publication?
Yes No

If Yes, please provide title of publication:

10.
Will you receive any information about the material that might be considered confidential or proprietary?
Yes No

If yes, please explain:

11.
Planned use of the material (please outline the specific experiments; also attach any relevant letters or e-mails exchanged with provider regarding planned use of the material (a project summary/abstract, etc.):

12.
Will you create derivatives or make modifications to the material (e.g. subcloning plasmids, transfecting cell lines, crossing animals, chemically modifying material etc.)?
Yes No

If Yes, please explain:

13.
Will material be used in conjunction with other materials or with equipment received or requested (not purchased) from other providers?
Yes No

If Yes, please identify these other materials/equipment and their providers:
(a)
(b)

If Yes, is there an agreement, statement, letter of intent or correspondence of any kind between you and these providers?
Yes No

If the research involving the material requested herein involves: (a) Recombinant DNA materials, (b) Infectious microorganisms, regardless of pathogenicity, and/or (c) Human or non-human primate blood, cell lines or unfixed tissues, you must be registered with the COMS Committee. If you have not yet done so, please contact Theodore Myatt, BWH's Biosafety Officer to register: Email: TMyatt@partners.org, Phone: 617-724-4579 Fax: 617-726-5126.

14.
14. Do you have any other collaborators (either at BWH or another academic institution or a company) on the project in which the material will be used?
Yes No

If Yes to either of the above, please explain the nature of the collaboration, as well as contact information (phone/e-mail) for the collaborator(s):


15.
Does your lab receive industrial support for:

(a) the project in which material will be used?
Yes No

(b) any portion of the Principal Investigator's salary or the salary of individuals working on the project?
Yes No

(c) the purchase of supplies, reagents, animals, tissues or cells required for the project?
Yes No

If Yes to any of the above, please explain briefly:


16.
Please indicate all sources of support (other than industrial) for the project, e.g. NIH and foundation grants, fellowships awarded to investigators, etc.:
Sponsor(s):

Grant title(s):

Grant number(s), if known:


17.
Will the anticipated discoveries or new materials you make in the course of the project using the requested material have clinical or commercial applicability?
Yes No

If Yes, please explain:

Do you have any issued or pending patents, or have you ever filed an invention disclosure related in any way to the project?
Yes No

If Yes, please explain:


IF YOU ARE NOT RECEIVING HUMAN SAMPLES/TISSUE, PLEASE GO DIRECTLY TO THE SIGNATURE LINE BELOW

IF YOU ARE RECEIVING HUMAN SAMPLES/TISSUE, PLEASE FILL OUT THE FOLLOWING QUESTIONS:

Tissue refers to ANY specimen obtained from patients or human research subjects, e.g.: fixed, frozen or fresh pathology or autopsy specimens, any blood, urine, saliva, semen, breast milk or other biological material obtained from humans, any purified DNA, RNA, proteins, cell lines or clones, whether collected primarily for clinical purposes or specifically for research. Regardless of how the tissue was obtained, the proposed use of this tissue for research must be reviewed by the Partners IRB. (www.healthcare.partners.org/phsirb)

18.

Please indicate the estimated length of time the research will take.

19.
Please provide the Partners IRB protocol number and title, and attach a copy (cut & paste) of the protocol and a copy of the Partners IRB's determination (approval letter, exemption determination, etc.). If you only have hard copies, please fax them to Renee Tetrault at (617) 954-9361.

20.
Has the Partners IRB specifically approved the use of these materials by your lab?
Yes No

If No, please explain why approval is not relevant/required:


21.
Under what circumstances were the samples collected from the patients?
Surgical procedure
Blood draw
Delivery/obstetric procedure
NIH or company-sponsored clinical trial / research
(If company, please provide company name.)

Other

If Other, Please explain:

22.
What form of consent was obtained from the patients?
Providing Entity's standard procedure consent
Providing Entity's standard Consent for Obstetrical Procedures and Activities
Study-specific written consent (please append)
None or don't know

If "None or don't know", please explain:

23.
Will any patient information or other clinical data be transferred with the samples?
Yes No

If Yes, will the information/data contain any of the following identifiers (please check applicable box(es))?

Name Address by street location Address by town/city/zip code
Telephone number Fax number Electronic mail address
Social security number Medical record number Account number
Certificate / license number Web URL's Full face photographic image
Medical device identifiers and serial numbers Internet protocol (IP) address Biometric identifiers (finger and voice prints)
Dates (except year), e.g., date of birth; admission/ discharge; date of procedure; date of death Health plan beneficiary number Vehicle Identification number and serial number, including license plate number
Any other identifier or combination of identifiers likely to identify the subject

PLEASE NOTE: The transfer of samples with identifiable information may carry additional requirements (e.g., patient consent and authorization) under federal human subjects regulations and/or the HIPAA Privacy Rule. If the identifiers transferred are limited to address by town/city/zip code, dates, and other identifiers not specifically listed above, the provider of the material (if it is a "covered entity" under HIPAA) may require that a data use agreement be put into place before the transfer occurs. Please forward any such data use agreement to CSRL for review.


Please be aware: There may be terms and conditions in the Material Transfer Agreement which preclude your use of the materials in research sponsored by industry, limit your ability to commercialize your inventions or prevent you from obtaining other materials for the same project. Please let CSRL know of any special concerns you may have with respect to the material.


I CERTIFY THAT I HAVE READ THE QUESTIONNAIRE AND THAT ALL INFORMATION PROVIDED IS ACCURATE.

This Information Form will be submitted electronically and validated by electronic signature. I represent that I am the Principal Investigator named in the Information Form and I type my name as an electronic signature.

 
  Signature of Principal Investigator
(no per signatures please) 		Date
Download Form. Principal Investigator must sign the printed form before submitting by fax or interoffice mail.
MTA In Form.doc
MTA In Form.pdf