HTML Preview Transfer.pdf page number 1.
Materials Transfer No.
THE UNIVERSITY OF MICHIGAN
MATERIALS TRANSFER FORM
(see back of form for instructions)
Date Prepared
SUBMITTED TO:
MATERIALS REQUESTED:
3.
Org. Code
Telephone
PROPOSED TIME PERIOD FOR USE AND POSSESSION OF MATERIALS:
COST OR FEE FOR MATERIALS:
6.
Use of human subjects / patients
Use of vertebrate animals
Use of radioisotopes in or on humans
Use of radioactive material
Use of recombinant DNA
Use of human body substances
Use of etiologic agents
Classified research
Restrictions on openness of research
Work off University property
Are requested materials dangerous to handle, store or use?
If yes, IRB approval number & date
If yes, date of RPC approval
If yes, contact DRDA Project Representative
If yes, identify location of research
If yes, how?
If yes, DRDA will notify UM Risk Management Office
NOTES:
Written agreements from the provider to allow transfer of materials must be signed by someone specifically authorized by the Regents to sign
agreements and contracts on behalf of the University. DRDA will secure such properly authorized signatures.
We certify the proposed work is consistent with University unit objectives and all faculty involved in the proposal have agreed to participate.
We accept the obligations and commitments described, and agree to perform the work in accordance with University and sponsor policies.
NOTICE: Principal Investigator and Chairperson will bear responsibility for monitoring compliance with agreement terms.
Approved by: Dept or Unit Head
Requested by: Principal Investigator
Approved by: Dean
Approved for DRDA by: Project Representative
Approved for the University
If yes, IACUC approval number & date
If yes, date of committee approval
If yes, specify Exempt, Biosafety Level I, II, III, or
human gene transfer
If yes, specify
If yes, contact DRDA Project Representative
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Principal Investigator/Requester
uniqname
Department / Unit
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Provider
Provider Address (see instructions)
Start Date
End Date
Do the Principal Investigator, Participating Investigators, or other key investigators have “significant financial interest or
management interest” in the proposed project that may constitute the basis for a conflict of interest? See Instructions for
Policy Statement.
Signature of Principal Investigator
No
Yes
If yes, specify
September 1999
DOES THE PROPOSED ACTIVITY INVOLVE:
2.
4.
5.
1.
7.
Administrative Contact
uniqname
Address
Telephone
Fax
The following activities, if marked YES, may require further registration/inspection/approvals by appropriate institutional committees.
Establishment of an agreement may be delayed until approvals are granted.
Use or Derivation of Human
Pluripotent Stem Cells
No
Yes
If yes, date of HPSCRO Committee approval