Basic Information 1. Principal Investigator: 2. Department Administratively Department Name: Responsible for this Agreement: Department ID: 4. of Submission: 5. Department Administrative Contact for PI Name: Contracting Party Information 1 Contracting Party Name: 2. Legal Contact Name: 3. Legal Contact E-Mail Address: 4. Contact Phone Number: 5. Scientific Contact Name: 6. Scientific Contact E-mail: 7. Does the Principal Investigator have a Yes financial relationship with any of the No Contracting Parties listed above that is or should be disclosed on your If Yes, please explain: University of Pittsburgh Conflict of Interest disclosure form? Material Information 1. Identify all materials being shared under this MTA: 2. Do these contain biological material? Yes No Material Source Information 1. Was all material independently Yes developed by you or under your No direction at Pitt? If no, please explain: 2. Does the material incorporate or is Yes the material derived from materials No obtained from a If Yes, please explain: Third party? 3. Was any of the material brought to Yes Pitt from somewhere else? No If Yes, please explain: 4. Are alternative sources to provide Yes the material? No If Yes, please explain: 5. Is the material under disclosure to or Yes patented by Pitt Office of Technology No Management OTM Staff Member: (OTM)? OTM Case Number:
Basic Information 1. Principal Investigator: 2. Department Administratively Responsible for this Agreement: Department Name: Department ID: 4. of Submission: 5. Department Administrative Contact for PI Name: Contracting Party Information 1 Contracting Party Name: 2. Legal Contact Name: 3. Legal Contact E-Mail Address: 4. 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: Material Information 1. Identify all materials being shared under this MTA: 2. Do these contain biological material? Yes No Material Source Information 1. Was all material independently developed by you or under your direction at Pitt? Yes No If no, please explain: 2. Does the material incorporate or is the material derived from materials obtained from a Third party? Yes No If Yes, please explain: 3. Was any of the material brought to Pitt from somewhere else? Yes No If Yes, please explain: 4. Are alternative sources to provide the material? Yes No If Yes, please explain: 5. Is the material under disclosure to or patented by Pitt Office of Technology Management (OTM)? Yes No OTM Staff Member: OTM Case Number: