Basic Information 1. Principal Investigator: 2. Department/Institute/Center that will Department/Institute/Center Name: be administratively responsible for Department/Institute/Center ID: this Agreement: 3. Is the draft of the agreement Yes, Draft agreement attached 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 Contracting 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 Yes financial relationship with any of the No Contracting Parties listed trial that is or should be disclosed on your If Yes, please explain: University of Pittsburgh Conflict of Interest disclosure form? General Information Yes 1. Is this CDA/NDA to permit No discussions solely regarding commercial licensing activity If YES, please direct your request to the Office of Technology Management (OTM) with the other party? Yes 2. Is this CDA/NDA related to your No potential private consulting activity with the other party? If YES, The Office of Research cannot review this CDA/NDA. You should review any consulting arrangement with your Chair.
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 Contracting 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 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. trial
Confidentiality%20Agreement%20Submission%20Form%20-%20%20LEGACY%20-012115_0.docx