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REQUEST FORM

Non-Disclosure/Confidentiality and Material and/or Data Transfer Agreement

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Agreement Templates
Current Page: Agreement Request

Please use this form to request assistance with an incoming or outgoing NDA/CDA or MTA/DTA associated with an active sponsored project. A Document Summary Sheet is required to verify the request. If you have questions about this form or the drafting/review process, please contact Miriam Allen.

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Is this request associated with an active or anticipated sponsored project?

YesNo

What is the Document Summary Sheet number?

Is this request:

Necessary to accomplish the aims of a sponsored projectAncillary to the project

OSP only works on the agreements that involve active sponsored projects. Please submit a request through PIVOT Center. https://pivotcenter.utah.edu/tvc-agreement-request/

Sponsored Project Information

Does this activity have external funding?

YesNo

Is this Agreement Incoming?

YesNo

Attach proposed draft if available

Is this Agreement Outgoing?

YesNo

Attach proposed draft if available

University of Utah Primary Contact Information

First Name

Last Name

Department

Email Address

Phone Number

Are you the Principal Investigator (PI)?

YesNo

Is the PI a Huntsman Cancer Institute (HCI) Investigator?

YesNo

University of Utah PI Contact Information

U of U PI First Name

U of U PI Last Name

Administrative Department (as listed in the DSS)

U of U PI Email Address

Do you have a co-PI?

YesNo

Co-PI Contact Information

Co-PI First Name

Co-PI Last Name

Co-PI Email Address

Other Company or Institution

Other Company or Institution Name

Other Physical Address

Mailing Address (if different from above)

City

State

Country

Zip/Postal Code:

Contact Information for Other Company or Institution

Other Company/Institution Contact First Name

Other Company/Institution Contact Last Name

Other Company/Institution Contact Email Address

Is this the PI for Other Company or Institution?

YesNo

Other PI Contact Information

Other PI First Name

Other PI Last Name

Other PI Email Address

Other Phone Number (if available)

Required Agreement Information

What is being shared or transferred?

Physical MaterialDataInformational Only

What type of materials?

HumanNon-human (i.e. mice, software code, metal, etc.)

What patient population?

How many patients?

How many samples?

What are the samples? (i.e. tissues, cells, blood, etc.)

Please describe the data

Was the data collected under a research study or standard of care?

YesNo

If yes, do you know if any third-party constraints may exist?

Does the applicable informed consent form allow the proposed use or transfer of data?

YesNo

What is the purpose of the transfer or aims of the research to be performed with the material and/or data?

Is University of Utah sending or receiving the above?

SendingReceivingBoth

Is the material and/or data human-related in any way?

YesNo

IRB Number

Is there a fee associated with the materials and/or data?

YesNo

If yes, please explain

Additional Questions

What is the requested period of the agreement?

When will the transfer occur?

How long will recipient use materials and/or data?

What will happen to any remaining materials and/or data after the research has been completed?

What is the level of identifiability?

De-identified

LimitedIdentified

Additional Comments

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Last Updated: 12/1/22